THE RENEWAL OF LIFE. 



LECTUKES 



CHIEFLY CLINICAL 



„ 



THOMAS KING CHAMBERS, M.D., 

HONOE.IEY PHYSICIAN TO H. E. H. THE PRINCE OF WALES 5 
PHYSICIAN TO ST. MAHY's AND THE LOCK HOSPITALS. 



£xam t\xt ©tmrt f&nntXtin (&Mti*n 



PHILADELPHIA: 

LINDSAY AND BLAKISTON 
1865. 












henp!Y b ashmead, printer, 

1102 and 1104 Sausom Street. 



PREFACE 



THIRD EDITION. 



In two former editions I named the selection of clinical 
observations which I laid before the public " The flenewal 
of Life," intending thereby to intimate what is more fully 
stated in the first and second introductory chapters, that 
the main point for the physician's consideration in disease 
is the deficiency of vital action, and that all successful 
medical treatment is a renewal of that vital action. To 
my regret the words have been found strangely " open to 
misrepresentation" by several of the literary men engaged 
in reviewing the work. Such a risk seems to outweigh 
the advantage of expressing in an epigrammatical form 
the principles advocated, and has led me to take the 
unusual course of leaving out a great part of the title. 
But I am more than ever impressed with the importance 
of these principles in practical therapeutics, and have 
enforced them anew by revising carefully the original 
matter, dovetailing into it many remarks made to my 



vi PREFACE TO THE THIRD EDITION. 

class on recent passing cases, and adding twenty-three 
new lectures, three given at the College of Physicians, 
and the rest in my post as a teacher of medicine at St. 
Mary's Hospital. 

The original first lecture was published as a field for 
the discussion of conflicting theories by those who did 
me the honor of criticism. That object having been 
attained, and answers given in a concluding essay, the 
greater part of it has been omitted, and the remains 
interpolated elsewhere. 

It may be remarked that most of the "Lectures," as 
here presented to the reader, combine materials orally 
delivered at several, and often at distant, times. These 
are obviously short fragments of lectures, made still 
shorter by the omission of the elementary instruction 
on diagnosis. They are here united under subjects, and 
to avoid chronological confusion the dates of their viva 
voce production are set at the head of each. I trust the 
disjointed aspect thus given will be pardoned, as we par- 
don, in a portfolio of sketches made on the spot, rough- 
nesses inexcusable in the finished works of the studio. 

T. K. C. 



CONTENTS 



LECTURE I. 

DEATH AND LIFE. 



PAGE 



Reasons for an introductory lecture — Decay of dead bodies — Decay of 
living bodies — Life is renewal, and cannot be in excess — Health, 
death, and disease — Illustrations of partial death as exhibited in 
disease — in degenerations — in hypertrophies — in malignant tumors 
— in catarrh — in boil and abscess — in fever and zymotic diseases — 
in ancemia — in mixed anaemia — in tuberculosis — Classes of dis- 
eases in the hands of the nosologists — The restorative direction of 
modern improvements in medicine — Constructive and destructive 
life — Restorative pharmacopoeia . . . . .25 



LECTURE II. 

DISEASE AND CURE. 

What is cure? — Classification of disease, for therapeutical purposes, 
into deficiencies of growth and deficiencies of moulting — Deficien- 
cies of growth from CJiossat's observations — Analogous natural 
states in disease — Deficiencies of moulting — True and apparent — 
Mixed lesions — Natural cure and artificial cure — Cure originated- 
by the healthy parts of the body — Classification of means of cure — 
Constrictives — Destructives — Arresters of construction — Arresters 
of destruction . . * . . . .42 



viii CONTENTS. 

LECTURE III. 

FORMATION OF MUCUS AND PUS. 

PAGE 

Office of mucous membranes — The identity of mucous globules and nascent 
epithelium — Self -supported growth of mucous globules — Similar to 
organic growth of a parasite — Is this form of an excess or a defi- 
ciency of normal life ? . . . . .66 

LECTURE IV. 

FORMATION OF MUCUS AND PUS. 

Mucous globules not cells, but nuclear matter — The representative of the 
cell is the medium in which they float — It is therefore not likely to 
retrograde into globules — Formation of pus from mucus — How 
does pus appear on the surface? — Observations of several observers 
— Passage of globules through epithelium — Pus-globules not de- 
scendants of epithelial cells, but parasitic formations inside them 
— Epithelium semifluid — Breach of epithelium in some cases — 
Growth of pus . . . . . . .74 

LECTURE V. 

FORMATION OF MUCUS AND PUS. 

Mucus and pus compared — Grades of loss of vitality in mucous mem- 
branes — Exemplification of these grades in small-pox pustules — 
Practical deductions from the various points commented on in the 
three lectures . . . . . . .84 

LECTURE VI. 

TYPH-FEVER. 

Case — Cause of fever — Why it affects some and not all — The virus acts 
slowly, and enters probably by the alimentary caned — Case showing 
the progress of fever-poisons checked by emetics — Action of fever- 
poisons on living organism — Devitalizing power on blood — The first 
symptom of partial death is a rigor — Next symptom, pain — Loss 
of appetite which does not arise from defective metamorphosis — 
diarrhoea, hemorrhage, and increased heat, all are evidences that 



CONTENTS. ix 

PAGE 

disease is something less than life — The object of treatment is not 
the mere typh poison, but the interstitial death of the tissues — The 
touchstone of restorative medicine is its application — Use of emetics 
— Tepid sponging — Cold affusion removes but does not check the 
formation of heat — Supply of food — Hydrochloric acid — Alcohol — 
Local blood-letting — Principal difference between patients lies in the 
stomach — Two instances — Deduction . . . .98 



LECTURE VII. 

TYPH-FEVER. 
Therapeutical statistics ....... 118 

LECTURE VIII. 

TYPH-FEVER. 

Cases with running commentary — Relapse of rose-spots — Contagion 
from patients to a nurse — Leeches and mercury — Mulberry-rash — 
Intermittent pulse — Rose-spots or mulberry -spots, which the most 
dangerous ? — Wine in fevers — Retarded emaciation — Subcuticular 
eruption — Contagion — Artificial cuticle in bed-sores — Sudamina — 
Low condition in convalescence, its symptoms . . . 122 

LECTURE IX. 

TYPH-FEVER. 

Part I. — Three fatal cases since October, 1861 — One brought in mori- 
bund, one treated with hydrochloric acid, &c, one not — Four cases 
in hospital related, with comments — Danger of giving solid food 
too early in convalescence — Absence of enteric symptoms best guide 
to administration of solids — Dose of hydrochloric acid for children 
— Connection of typh-fever and pneumonia — Small-pox caught 
during convalescence from typh-fever . . . .128 

Part II. — Additional case, illustrative of the connection between the tivo 



x CONTENTS. 

PAGE 

forms of typh-fever eruptions — Precautions in case of threatened 
pneumonia — Caution against moving patients in fevers . .134 

Part III. — Four additional cases with comments. Case 1. — Difficulty 
of distinguishing typhus and enteric fever — Relief of enteric pain 
— Dry, glazed, cracked tongue in enteric cases — Arrest of diarrhoea 
by hydrochloric acid, by Dover's powder, &c. Case 2. — Fever spots 
and jlea-bites — Fever cut short by an emetic — Emaciation during 
convalescence not prevented by the cutting short of the fever. Case 
3. — Fever cut short by an emetic — When not arrestive, this treat- 
ment is palliative. Case 4. — Fever contracted in the hospital 
aggravated nearly to a fatal extent by inflammation of previously 
diseased genital organs and bladder, and by a slough on the 
sacrum — Treatment . . . . . . .138 

Part IV. — Case of typh-fever contracted in the hospital by a patient 
admitted for acute rheumatism — Emetic only partially successful — 
Administration of solid food and wine .... 142 



LECTURE X. 

SMALL-POX. 

Part I. — Case of small-pox watched from first infection— Sequence of 
phenomena — Memoria technica by which to remember them — Use of 
observing them — Action of oxygen on the general health of the 
patient and on the shin contrasted — Microscopical examination of 
the contents of the pocks, with practical deductions therefrom — 
Depth of injury to skin in small-pox — Reasons for cutting the 
hair . . . . . . % . . 145 

Part II. — Spread of small-pox in the hospital from the above case — 
Example of the use of vaccination in modifying the disease — Ac- 
tion of vaccinia not homoeopathic or counter-irritant, but preventive 
— Infectiousness of small-pox compared with other diseases — Dif- 
ferent degrees of infectiousness demand different precautions . 150 



LECTURE XL 

RHEUMATIC FEVER. 

Relations of the practitioner and lecturer to rheumatic fever — Descrip- 
tion of treatment — (1) Bedding — (2) Fomentations — (3) Remedial 



CONTENTS. xi 

PAGE 

agents — Bicarbonate of potash, Iodide of potassium — (4) Opium — 
(5) Leeclies — (6) Poultices in pericarditis — (7) Diet — Commenta- 
ries on the restorative agencies of the aforesaid treatment . . 155 



LECTURE XII. 

RHEUMATIC EEVER. 

Exceptional cases of rheumatic fever — Inflammation of heart arrt 
by epistaxis — Delirium and gangrene in rheumatic fever — Treat- 
ment — Case of rheumatic fever in a tubercular subject, with conse- 
cutive purpura of the legs — Treatment by lemon juice . . 167 



LECTURE XIII. 

RHEUMATIC FEVER. 

Therapeutical statistics . . . . ' . . .. 174 

LECTURE XIY. 

GONORRHOEAE RHEUMATISM. 

Case. — Name of disease not strictly correct — Its relation to pycemia — 
May occur at any period of the gonorrhoea— Not a metastasis — Ob- 
jection to any treatment grounded on its being a metastasis — Ure- 
thritis a worse disease than gonorrhoea — Possible peculiarity of 
gonorrhceal virus in these cases — Parity of such severe cases as this 
shown by the results of seventeen other cases, ivhich represent the 
more usual aspects of the disease— Specimen of a more usual case 
of gonorrhceal rheumatism and its , treatment — Recurrence of gonor- 
rhceal rheumatism , . . . . . . 179 

LECTURE XV. 

PERICARDITIS. 

Case of pericarditis coming on in the hospital — Rarity of this circum- 
stance — Explanation of its occurrence in this instance — Diagnosis 
of old and recent disease by the physical signs — Practiced value of 



xii CONTENTS. 

PAGE 

diagnosis — Treatment — Leeches — Blisters — Poultices — Prevention 
better than cure — Case illustrative of the use of mercury in similar 
circumstances, and the reason why it is no longer employed by the 
author — Fatal case of pericarditis from exposure to the cold during 
convalescence from typh -fever — Two cases of pericarditis, one aris- 
ing from a linen shirt-front next the skin during rheumatic fever, 
the other of doubtful origin — Action of opium on thepidse — Varia- 
tions in the pulse — Remarks on the pain of pericarditis — Case 
illustrating its absence, and the non-reduction of the pulse by opium 
— Fatal pericarditis in a patient of choreic diathesis . . 191 



LECTURE XVI. 

PLEURISY. 

First case, and its treatment — Cases of pure pleurisy not common in 
hospital practice — It is a slight disease, but capable of being made 
much more severe by bad management — Remarks on blisters and on 
local blood-letting — Their final intention restorative — Poultices — 
Continuous warmth as a renewer of life — Second case — Chronic 
effect of acute pleurisy — Treatment — Diuretics — Third case — Py- 
cemic pleurisy, its fatality ...... 204 



LECTURE XVII. 

HYDROTHORAX. 

Term "idiopathic hydrothorax" justified — Form of pleuritic disease — 
Which form is here intended — two cases — Hydrothorax, a collection 
of fluid in the pleura — Difference between collection and effusion — 
Source of the fluid — Action of physical agents in the production of 
the disease — Treatment founded upon the pathology — Blisters — 
Poidtices — Mercury — Food — Digitalis — Squill — Niter — Scopari- 
um — Sequel of the second case, seven months afterward— State of 
chest, and explanation thereof -^-Another case of displaced heart — 
Treatment by paracentesis — Large quantity drawn off without re- 
turn of heart — Comparison of these two cases as to treatment — 
Results inferred from them, and from an analogous case of empye- 
ma, opening externally , „ . . . .213 



CONTENTS. xiii 

LECTURE XVIII. 

ACUTE LARYNGITIS. 

PAGE 

Case related — Important point in the pathology of the disease is its 
locality — Tracheotomy must not be represented as a last hope — 
Reasons for delaying it and reasons for not delaying it — Care of 
digestive organs — Wine — Solid food — Antimony — Mercury — La- 
ryngitis, acute and chronic — Difference in pathology and in prin- 
ciples of treatment ....... 231 



LECTURE XIX. 

CAPILLARY CATARRH. 

Definition of the disease — The mildness and severity depend on the 
quantity of bronchial membrane involved — Slight cases essentially 
of the same nature as the severe cases here brought forward — (First 
case) Uncomplicated bronchial catarrh — (Second case) The same 
arrested on the brink of merging in broncho-pneumonia — Treatment 
by warmth and moisture — The same treatment (Mudge's) applicable 
to mild cases — Blood-letting — (Third case) Bronchial catarrh fatal 
by supervening on lung previously imperfect — Autopsy — -Such form 
of fatal disease aptly described as paralysis of the lung — Equally 
fatal to strong as to puny people — Arises from exposure to cold air 
during a catarrh — Danger much increased by imperfection of lung 240 



LECTURE XX. 

PNEUMONIA. 

Three cases of pneumonia — 1. Frank uncomplicated double pneumonia 
in a temperate man, with excessive dyspnoea — Cured with venesec- 
tion, jacket-poultice, continuous feeding and wine. 2. Pneumonia 
of upper and lower lobes of one lung, very slight in the other lung, 
in a broken-down old man — Cured with cupping, jacket-poultice, 
continuous feeding and wine. 3. Congestive pneumonia of lower 
lobe in typh-f ever— Cured with half jacket-poultice, cupping beneath 



xiv CONTENTS. 

PAGE 

scapula, continuous feeding, wine and bark — Commentary — Patho- 
logy of pneumonia — Importance with proportion to quantity of 
tissue involved, not to stage of progress — Hence the value of a ready 
and quick means of checking its progress — Blood-letting — Action 
of it — General and local compared — III effects of loss of blood — 
Mode of judging of the necessity for it — Compensation for it — Poul- 
tices — Their action — Especially adapted for infants — How to make 
them — Alcohol, when required — Effect of position in the pneumonia 
oftyph-fever — Blood-letting — Purgatives — Blisters — Antimony and 
mercury ........ 248 



LECTURE XXI. 



PNEUMONIA. 



Record of six cases during recess — {1st Case) Caution about blood- 
letting — (2d Case) Pneumonia of upper lobe in third stage, viz., of 
abscess — Repeated attack of pneumonia during convalescence, fatal 
to this patient — Post-mortem examination — Remarks on treatment 
— Cause of second attack — (3d Case) Pneumonia in Bright' s dis- 
ease cured — Slate of lung afterward — (4th Case) Pneumonia in 
measles — Catarrhal pneumonia — (5th Case) Pneumonia treated 
with opium — When opium is desirable — Reduplicating pulse — (6th 
Case) Pneumonia in a pregnant woman treated with opium — Re- 
marks on vomiting in pregnancy — Additional cases present in hos- 
pital — (7th Case) Early occurrence of pneumonia in typh-fever — 
(8th Case) Double pneumonia in a fatal case of delirium tremens 
■ — (9th Case) Double pneumonia slowly progressing from one lung 
to another — Pleurisy also on one side — Food in convalescence — 
Mode of recovery of consolidated lung — (10th Case) Catarrhal pneu- 
monia— Severity of symptoms atfrst, and rapid relief— Treatment 
by poultices and local blood-letting— (11th Case) Double pneumonia 
in a man of drunken habits — Also catarrhal, and therefore distin- 
guished by the severity of the symptoms at first — Treatment with 
opium, poultices, and cautious cupping — Delirium — Wine — (12th 
Case) Pneumonia morientum in death from other causes — Reca- 
pitulation ........ 261 



CONTENTS. xv 

LECTURE XXII. 

EMPHYSEMA OF LUNGS. 

PAGE 

Illustration of the morbid anatomy of emphysema — Fatty degeneration 
of the pulmonary membrane — Degeneration sometimes fibroid — 
Cause of the proneness of children's lungs to become emphysema- 
tous — Questions whether inspiration or expiration most tends to 
produce emphysema — Action of the lungs in breathing illustrated 
by an example of a man without a sternum — Expiration more pow- 
erful than inspiration — Application of the morbid anatomy of 
emphysema to clinical questions — Case of emphysema in an albu- 
minuriac — Case of emphysema depressing the heart — Treatment 
and its objects — Iron — Tobacco — Lobelia — Stramonium — Mercury 
— Alcohol — Expectorants — Two cases of emphysema in young wo- 
men exposed to adverse circumstances — Treatment by iron — Trial 
of expectorants ....... 283 



LECTURE XXIII. 

PULMONARY CONSUMPTION. 

Pathological data — The disease localized by morbid anatomy and aus- 
cultation — Pitfalls of this knowledge — Not the presence, but the 
increase, of tubercle, is the chief point — Innocuousness of non-pro- 
gressive tubercle — Object of treatment should be the organs of nutri- 
tion, not those of respiration — Food — Cough medicines — Appetite 
— Iron — Cod-liver oil — Alcohol — Remedies for diarrhoea — Cachec- 
tic phthisis — Chlorate of potash — Delirium in the last stage of 
phthisis, how caused, and how to be treated — Specifics . . 297 



LECTURE XXIV. 

THORACIC ANEURISM. 

First case of aneurism, probably of the innominata — Reasons for diag- 
nosis — Aortic valvular murmur accounted for — Probable abnormal 
position of artery — Prognosis unfavorable — Second case — Aneu- 
rism of aorta and its treatment — Blood-letting and low diet — Patho- 
logy of aneurism — Object of treatment — Favorable prognosis — Two 



xviii CONTENTS. 

LECTURE XXX. 

CHOREA. 

PAGE 

Part I. — Case treated without drugs — This case a recent one — Principle 

of treatment. ....... 394 

Part II. — Four long continued hut curable cases treated with arsenic — 
Quoted as specime?is of the disease as usually seen — Effect of forci- 
ble control over the movements ..... 398 

Part III. — Records of three fatal cases and two unaffected by treatment 
— Connection of chorea and rheumatism and disease of heart sta- 
tistically deduced from the records of thirty-three cases under my 
care ......... 403 



LECTURE XXXI. 

EPILEPSY. 

Cases illustrative of the use of iodide or bromide of potassium — Sug- 
gested explanation of the benefit so derived — Accessory treatment . 407 



LECTURE XXXII. 

HYSTERIA. 

Part I. — Hysteria not fated, but not therefore unimportant — Not a 
uterine disorder — Its pathology lies between mind and body — Its 
forms to be divided according as it approaches one or the other — 
Such a division has a direct bearing on the treatment — Mental hys- 
teria — Treatment, restoration of voluntary mental force, of cutane- 
ous circulation, and of emotional control — Corporeal cause for 
hysteria — Treatment, tonic to mucous membranes — Effects of tea- 
drinking — Treatment, dietetic ..... 412 

Part II. — Hysterical vomiting — Three cases in hospital compared with 
some private patients — It is not in strictness vomiting — -Diagnosis 
and treatment — Their difficulties — Hysterical cough — Contagious- 
ness of hysteria ....... 427 

Part III. — Connection between hysteria and insanity illustrated — Medi- 
cal curiosity about private history of patients — A physician not a 
confessor ........ 432 



CONTENTS. xix 

PAGE 

Part IV. — Periods of life prone to hysteria — Blighted affections, low- 
ering diseases, and climate, as causes — Two cases of hysterical loss 
of voice treated by valerian and shower-baths — Spasmodic cough 
and spitting of blood in one patient — Advantages of auscultation 
in the diagnosis of the latter ..... 434 

Part V. — Treatment by ice — Treatment by blood-letting — General con- 
clusions ........ 439 



LECTURE XXXIII. 

SPINAL PARALYSIS. 



Case of paralysis caused by meningitis of the spinal cord — Action of 
iodide of patassium ....... 



LECTURE XXXIY. 



SCIATICA. 



442 



Anatomical pathology of the disease — Case of rheumatic sciatica — Ro- 
kitansJcy's description of the morbid anatomy of sciatica — The 
disease a local one — Therefore requiring local remedies — Case of 
gouty sciatica — Relief from cupping — Peripheral pain sometimes 
more lasting than central disease — Sciatic paralysis of bladder — 
Case of ancemic sciatica — Local treatment first requisite — Use of 
iodide of potassium — And of quinine — Other forms of sciatica — 
Other remedies besides those named — Deductions and reflections . 44G 



LECTURE XXXV. 

ALBUMINURIA. 

Indications afforded by the presence of albumen in urine, and 'progno- 
sis derived therefrom — Treatment, based not on anatomical division 
of forms of degeneration in the kidney, and not on the quantity of 
albumen, but on the circumstances accompanying its presence — 
Adjuvantia, viz., iron, digitalis, strychnia — Lcedentia, viz., mer- 
cury, calomel — When each are justifiable — Treatment of dropsy by 
baths, jalap, cream of tartar, elaterium, and acupuncture — Sloughs 
of skin, how treated ....... 455 



xx CONTENTS. 

LECTURE XXXYI. 

ALBUMINURIA. 

PAGE 

Case of albuminuria ivith vomiting from ague cured — Case of albumi- 
nuria fatal from sudden pneumonia — Case of albuminuria fatal 
from epistaxis, and loss of blood and albumen — With comments on 
each ......... 464 



LECTURE XXXVII. 

ASCITES. 

Part I. — Case of ascites from hepatic degeneration relapsing after 
tapping several times prevented from returning by the use of iron — 
Cause of the disease irremovable, yet the disease capable of cure — 
Pathology of ascites, and connection of the treatment with that 
'pathology ........ 472 

Part II. — Case of ascites from renal degeneration treated with iron 
and cured, though the albuminuria remains as before — Contrast of 
this with two cases of albuminuria from a remediable cause . 477 



LECTURE XXXVIII. 

DIABETES. 

Case of diabetes, with history of treatment adopted — Arrest of function 
of construction of diabetes — Saccharine diet wasteful and harmful 
— Test of treatment is gain of flesh — Patients to be made into car- 
nivorous animals — Sugar may be formed from flesh diet, or from 
hepatic tissue — But from dead not live tissue — How far a very strict 
dietary should be enforced — Opium — Cinchona — Iron — Iodide of 
potassium — Gratification of thirst ..... 482 



LECTURE XXXIX. 

MORTIFICATION. 

Complete death of a part contrasted zvith nekrobiosis — Case of mortified 
toes from cold and senile arteries — Treatment explained — Preserva- 



CONTENTS. xxi 

PAGE 

Hon of dead tissue from decomposition — Defense of weak vessels — 
Food — Appetite — Action of oxygen on sore places — Carbonic acid 
the normal atmosphere of internal parts — Superiority of nature's 
surgery to man's . . . . . . .489 



LECTURE XL. 

IMPORTANCE OF THE DIGESTIVE ORGANS IN THERAPEUTICS. 

Disease of the digestive viscera affects the whole body — Instances, tuber- 
culosis, degeneration, mental disease, gout and rheumatism — Di- 
gestive viscera the chief recipients of remedies, and not only of con- 
structive, but of destructive and arrestive remedies — Effects in 
disease of healthy and unhealthy digestion — Importance of replacing 
destructive by the aid of constructive action — Digestive tract single 494 



LECTURE XLI. 

INDIGESTION IN GENERAL. 

Justif cation of the term as designating a class of diseases— Position of 
it in nosology — Its importance — Examples — Its action on chronic 
disease — on acute disease — Use and abuse of purgatives — Cause of 
death in acute fevers — Mode of introducing food . . . 501 



LECTURE XLII. 

SLOW DIGESTION AND ACIDITY. 

Healthy digestion is easy, quick, and complete — Unhealthy digestion is 
painful, slow, and defective — Phenomena exhibited in unhealthy 

Hon — Heart-burn — Acidity . . . . .513 



LECTURE XLIII. 

PAIN IN THE STOMACH. 

Local weight, tightness, distention, dependent on excessive secretion of 

mucus — Gastric catarrh, acute and chronic . . . 526 



xxii CONTENTS. 

LECTURE XLIY. 

ERUCTATION AND VOMITING. 

PAGE 

Anatomy and physiology of eructation — Relaxation of oesophagus — 
Spasm — Analyses of gases by chemists — Deductions therefrom — 
Secretion of air by mucous membrane (?) — Defective absorption — 
Decomposition of food — Fermentation prevented by acidity — Classi- 
fication of morbid states in which eructation occurs — Indications of 
treatment in the several classes — Antacids — Astringents — Valerian 
— Ammonia — Sulphurous acid — Charcoal — Vomiting — Causes of 
— Indications afforded by the contents of the vomit — Remedies for — 
Hydrocyanic acid — Carbonate of magnesia — Opium — Chloroform 
— Leeches — Lime-water and milk — Brandy — Creasote — Valerianate 
of zinc — Ice — Possibility of starvation from vomiting of a purely 
functional character — Sea-sickness and its remedies . . 536 



LECTURE XLV. 

DIARRHOEA. 

Pathology of diarrhoea — Difference of it from mere frequency of evacu- 
ation — Division of diarrhoeas — Bilious — Watery — Muco-purulent 
— Bloody — Putrid — Their causes and indications — Supplementary 
and reflex diarrhoea — Infantile — In fever — Ulceration of bowels — 
Mucous flux — Copious solid matter — Acid diarrhoea — Use of opium 
— Riding — Cautions about traveling — Flatus in ilia — Charcoal, 
&c . 548 



LECTURE XLYI. 

COSTIVENESS AND CONSTIPATION. 

The difference between costiveness and constipation — Costiveness depend- 
ent on retained excernible matter — What diseases it accompanies — 
Cause, defective vitality — Effect on the nervous system and mind of 
retained excernible matter — Indications of treatment — Inconveni- 
ences of purgatives — Sort of purgatives to be adopted — Dietary — 
Water — Watering-places — Cautions in using them — Hydropathy — 



CONTENTS. xxiii 

PAGE 

Constipation — Causes — Irritating food — TJnabsorbable food- — 
Remedies — Flatulence in colon — Distinguished from that in ilia 
— Remedies — Slight cases difficult to relieve . . . 562 



LECTURE XLVIL 

DIETETICS. 

Thesis of Dietetics based on the principles of sparing the weakest part 
— /. Stomach — II. Intestines — III. Increase of absorption — IY. 
Delay of absorption — V. Gradual return to normal diet . . 572 



LECTURE XLVIII. 

CORPULENCE. 

Obesity to be distinguished from fatty degeneration — Origin of adipose 
tissue from food either containing fat or elements capable of con- 
version into it in excess over the respiratory consumption — Presumed 
possibility of relief by dietetic treatment — Tendency to obesity con- 
genital and hereditary — Deductions from thirty-eight tabulated 
cases as to the peculiarities of obese persons, and the exciting causes 
of their condition — Obesity a comparative hypertrophy arising out 
of a comparative vital deficiency — Principles of rational treatment 
thence deduced — Difficulties in enforcing their adoption — Specimen 
of detailed scheme of dietary — Limits to attempts at reduction — 
Drugs, such as liquor potasses, vinegar, iodine, and diuretics, dis- 
cussed — Belts and baths — Prognosis of obesity . . . 581 



LECTURE XLIX. 

ON PEPSINE. 

History of the use of gastric juice in medicine — Difficulties of its use 
obviated by preparation — Experience of its use in a few typical 
cases — Limits of advantages gained—Details of administration . 589 



xxiv CONTENTS. 

LECTURE L. 

ON ALCOHOL. 

PAGE 

Experiments shoiving the action of alcohol on the vital metamorphosis 
of the body, with a running commentary on each — Opposite opinions 
about the use of alcohol — Best guide to therapeutical use is physio- 
logical observation of its action on the healthy body — What is a 
stimulant f — The effect of alcohol is arrest of nervous function — 
How it comes to be an indirect restorative — Rules for the adminis- 
tration of alcohol — Form of administration . . . 589 



LECTURE LI. 

ON BLOOD-LETTING. 

Part I. — The power of reneioal in the animal body exemplified by the 
quick restoration of normal blood in an anaemic girl — Application 
of these facts to the artificial anosmia induced by blood-letting — 
The necessary conditions for the repair of ancemia — Starving and 
bleeding at the same time bad practice — Reasons for bleeding — 
Fallacies of the ancients . . . . . .612 

Part II. — Cases in which loss of blood is beneficial — In some cases of 
apoplexy — In pneumonia — In the congestions of typh-fever — In 
serous inflammations, in pleurisy, pericarditis, and peritonitis — 
In renal congestion and hcematuria — In paralysis of the circulating 
organs from over distent ion — In chronic diseases of the skin — 
Conclusion . . . . . . . .617 



LECTURE LIL 

ANSWERS TO OBJECTIONS. 
{Lectori benevolo. Not delivered viva voce.) .... 626 

L'ENVOI 634 



LECTURE I. 

DEATH AND LIFE. 

Reasons for an introductory lecture — Decay of dead bodies — De- 
cay of living bodies — Life is renewal, and cannot be in ex- 
cess — Health, death, and disease — Illustrations of partial 
death as exhibited in disease — in degenerations — in hyper- 
trophies — in malignant tumors — in catarrh — in boil and 
abscess — in fever and zymotic diseases — in ansemia — in 
mixed ansemia— in tuberculosis — Classes of diseases in the 
hands of the nosologists — The restorative direction of modem 
improvements in medicine — Constructive and destructive 
life — Restorative pharmacopoeia. 

[Introductory Clinicals, St. Mary's, October 4, 1861, and Oc- 
tober 2, 1862.) 

Before I enter, as a teacher of clinical medicine, upon my 
duty of showing you how to read the lessons which are spread 
out before your eyes in the hospital wards, it is my custom to 
give you an introductory lecture. I think this saves time in the 
end, for " claudus in vid antevertit cursorem extra viam," as 
Bacon tells us, and my object is to show you the way. Doubt- 
less all your past professional studies have been in a manner in- 
troductory to this crowning study ; your anatomy, and chemistry, 
and physiology, and the systematic principles of medicine learnt 
under me and my colleagues, have led up to this end. But I 
wish shortly to recall to your memory what points in those studies 
of life and death have the most special bearing on the matter in. 
3 



26 DEATH AND LIFE. 

hand, and to show how a consistent theory of therapeutics may 
be built up from them. 

It is true that there are, and always have been, practitioners 
who declaim against theories altogether, who even boast that 
they can do without them, and think them useless, not consider- 
ing that to express such scorn is as if we should be proud of not 
knowing what We do when we act, or what we say when we talk. 
To reason at all is to theorize ; no one without theorizing can 
direct a method of cure to a sick person except at haphazard. 
As a matter of fact, none of these objectors ever do prescribe 
without theorizing about either the individual sufferer or the class 
to which they refer his sickness, though not always able to put 
their theory into words. In short, the want of a guiding princi- 
ple to connect the loose facts of daily experience has at all times 
been felt. 

From this practical need have been bred the many systems of 
therapeutics stamping their mark from time to time on the his- 
tory of our art. They have sprung from the brains of working 
men at the bedside, not from philosophers in their closets. Their 
adopters have not necessarily any strong faith in their truth or 
universal applicability ; but the heart wearies for a chain to link 
together the scattered fragments of knowledge — a string for its 
pearls ; it must have an idea on which to codify the laws of ac- 
tion. 

It would be a long task to quote the curious systems founded 
on imperfect data, but numbering their hosts of followers in for- 
mer ages, which have been given up as false and dangerous : I 
do not wish twice to slay the slain. I shall content myself with 
putting before you that which influences me in my practice, to 
which I now proceed. 

Man's body may be likened to a stately mansion, made of 
beauteous but very perishable materials, all of which are always 
needing repairs to keep up the shapeliness and usefulness of the 
building. But not all in equal degrees ; some of the walls may 
stand unaided for years, while other parts may want almost 
hourly looking after. When the owner leaves the dwelling the 
repairs cease, and then we see, not all at once, but one after 



DEATH AND LIFE. 27 

another, the materials falling into ruin. It will serve a purpose 
in my argument to think over the several steps of this ruin for 
a few minutes. 

Already while the soul is withdrawing we know that changes 
begin, very obvious to even the most superficial observer. These 
changes are mostly due to the loss of water by evaporation. 
The eyeball loses its brilliancy and gets dry and flat, the features 
shrink, the gloss leaves the hair and skin. All this goes on 
all the more rapidly after decease, and then we hide our dead 
out of our sight, and the future fate of the body is less familiar 
to us ; we must search for exceptional cases or special observa- 
tions if we want to know what happens. These we may cull 
from sundry independent sources. Here is one which old bar- 
barous manners afford us. " Rizpah the daughter of Aiah, 
the concubine of Saul," watched for six months, from " the 
beginning of barley-harvest" in April, to the rainy season in 
October, "till water dropped upon them out of heaven," to 
guard the corpses of her murdered kinsmen from the beasts of 
prey. So long under the sky of Palestine did they hold out a 
quarry for the wild dogs and vultures. 

In a moister air decay is quicker, but still not so quick as is 
often supposed. Here is another observation redolent of the 
refinements of modern science. The notes made by M. Devergie* 
on the bodies at the Morgue at Paris, show that for two months 
and a half after decease the muscular structures still keep their 
natural forms and hues. Up to three months and a half, the 
scalp, eyelids, and nose so far retain their ordinary features that 
the age of the person may be told. It is four months and a 
half before complete destruction of the face occurs, or the bones 
become brittle, and the bulky muscles of the neck and thighs are 
converted into adipocere. So that we may call three months 
and a half a short time to be occupied by the decomposition of 
a human body. So long does flesh last as flesh, and tissue as tis- 
sue, and is not melted into its mother earth. 

Let us come forth quickly from these ghastly scenes of the 
charnel-house to the joyous bustle of brimming life, and ask 

* Devergie, " Medecine Legale," t. ii, chap. v. 



28 DEATH AND LIFE. 

how long it takes not a dead but a living body to decay ? " A 
living body decay ?" Yes, in truth ; but whereas in the former 
case it was a thing to make men shudder, the fading of a long- 
loved image, the tearing up of a fair garment, the fall of a dar- 
ling home, the violation of a worshiped shrine, the forcible di- 
vorce from our nearest and dearest — it is all this and more — in 
the latter it is associated with the fullest fruition of all that is 
joyous in existence, the bounding pulse, the free-drawn breath, 
the swelling chest, the thrilling feel of health, the highest uses 
of mind and body. Decay is more truly a part of life than it is 
of death ; for it goes on unstayed through the whole of corporeal 
being ; whereas, after dissolution, it gradually ceases, and ends 
its work with the reconversion of the organic particles into 
eternally changeless elements. The most living body is the most 
active in decay : the more bodily and mental vigor are displayed, 
the more quickly do the various tissues melt down into substances 
which are without delay removed by the excreting organs. The 
more the blacksmith toils with his arms and the more the states- 
man with his brain, the heavier bulk of carbon, nitrogen, oxygen, 
and hydrogen is thrown out by lungs, liver, skin, and kidneys. 
Do they then wear out by this constant use, friction, and drain ? 
No, no — the more bricks are removed from the old wall, the 
more new bricks will a good builder put in ; and so — provided 
that the supply is sufficient, and that the builder is a good one — 
the more rapid the drain — the newer and stronger and fitter for 
its uses will the body become. 

But I will leave generalities and try to represent in figures 
how long it takes by living decay for the living body to drain 
away, and to have its substance renewed. In the grim details 
which I recalled to your memory at the beginning of this lecture, 
the nitrogenous or fleshy parts were most accounted of and espe- 
cially named as giving shape and the general look of a man to 
the melting corpse. So of the nitrogenous parts we will now 
speak — How long are they in being removed by vital decompo- 
sition ? 

We may reckon with Drs. Bidder and Schmidt* that the body 

* ;< Die Verdauungssiifte und der Stoffwechsel," p. 400. 



DEATH AND LIFE. 29 

of a mammal contains 35*45 grammes of nitrogen per kilogramme ; 
and, therefore, that an animal of 130 lb. (which is the mean 
weight of a man) contains upwards of 4*6 lb. of nitrogen. 

Then again, taking our numbers from an equally sound and 
independent source, we may reckon with Baron Liebig* that the 
liquid and solid excreta of a man by kidneys and bowels for a 
year contain 16-41 lb. of nitrogen, or for three months and a 
half 4*7 lb. of nitrogen. 

That is to say, in three months and a half a quantity of nitro- 
gen is removed by excretion, or vital decay, equal to the quan- 
tity of nitrogen in the whole mass of the chief nitrogenous tissue. 

What attractions has this term three months and a half for 
us ? — what memories does it rouse ? Why, this was the very time 
we fixed upon for the fleshy framework of the corpse to melt away 
in. Here is a pregnant fact, a light thrown on the mysteries of 
nature from a most unpromising source ! Dead flesh and living 
flesh last as nearly as possible the same time — the former, if 
anything, rather the longer. As far as we can judge, the albu- 
men, fibrin, gelatin, &c, which make up the live body, differ in 
nowise from the same matters dead ; they are liable to the same 
changes, affected by the same reagents, and naturally are re- 
solved into their elements in the same time; just as the marble 
in the Apollo Belvidere is to a mineralogist the same stone as it 
was in the quarry, liable to the same accidents and possessed of 
the same properties, though temporarily endowed with a different 
value, and made god-like by its adventitious form. 

What, then, raises to the rank of living creatures, and clothes 
with loveliness the masses of organic matter which are growing, 
moving, breathing, thinking, all around us ? It is the power of 
the individual Life to create its own individual Form. A man 
has no right of property over the particles of his body, except so 
long as they remain particles of his body and retain his shape. 
He hardly calls Ms the snappings of his hair or the parings of 
his nails, much less the carbonic acid he exhales from his lungs 
or skin ; all that he throws off is by common consent claimed as 
a perquisite by the public ; and the battle-fields which he has 
*. Liebig's " Chemistry of Agriculture and Physiology," part i, chap. ix. 



30 DEATH AND LIFE. 

fertilized with his blood enrich, not him, but the peaceful farmer. 
Yet as long as these organic constituents retain the form im- 
pressed upon them by the individual life, they are more truly his 
than any portion of his inheritance. 

A conjectural theory has been hazarded that Life mysteriously 
endows living matter with a defensive virtue, which enables it to 
resist the chemical and other powers acting regularly on inor- 
ganic and dead matter. The most notable instance cited is the 
stomach, which digesting everything else is not itself digested. 
This consumer of flesh is itself made of flesh, yet is not con- 
sumed. An answer seems given to the witty philosopher, who on 
hearing an alchemist boast his discovery of an universal solvent, 
inquired " In what vessel do you keep it ?" The stomach says 
(it has been in the habit of saying wise things from the time of 
Menenius Agrippa), " In a vessel like me, which is destroyed in- 
deed continuously, but is continuously rebuilt." Recent re- 
searches show that living matter, such as parts of living animals 
swallowed for instance, is dissolved by the gastric juice, and 
moreover that its own epithelial coat is destroyed, but is immedi- 
ately replaced by a new one. By this activity of growth (the 
idea of the impudent members calling the belly lazy !), and by a 
constantly flowing supply of alkaline blood to neutralize any of 
the acid secretion which might penetrate too deep, it retains the 
same shape for threescore years and ten. But it has no privileged 
immunity against the solvent it makes. 

It is, then, the Form which constitutes the Self; and it is not 
the changing, decaying matter which "was mine, is his, and may 
be slave to thousands. " The organic materials are the property 
of the form only so long as it retains them, and no longer — they 
are a floating capital. Over the innate essential nature of the 
material it has no control. Life cannot make the brute materials 
which it uses live longer than that which it leaves unused, but it 
has the power of making them anew, and building them up into 
a certain shape for the time they are made to last. In short, 
Life rests on the metamorphosis or Renewal of the body ; as this 
renewal is more thorough, the individual is more perfect, and 
fulfills better and more completely the duties of its position. If 



DEATH AND LIFE. 31 

it stops altogether, the body is no longer living. If it partially 
stops, the order of normal phenomena is disarranged, and ease 
is expelled — there is a state which we call "cfo's-order" or "dis- 
ease." 

To speak, therefore, of "a superabundance of life," or of an 
" excess of vital action," is a contradiction in terms. There can- 
not be too active a metamorphosis of the tissues, for the fresher 
their organic constituents, the more serviceable they are, and the 
longer duration they have before them. There cannot be too close 
an adherence to that typical form which it is the business of 
metamorphosis to keep up, any more than there can be too exact 
an obedience to law and order. 

The most active metamorphosis of the body possible, the 
highest possible development of life in every part, is Health. 

The complete cessation of metamorphosis is Death. 

The partial cessation, or arrest, is Disease. 

In death the flesh goes on being decomposed as during life ; 
but not being renewed, the form is lost entirely. In disease, de- 
composition goes on, but renewal flags, and the decomposing 
tissues are not sufficiently pushed out by new-formed substance. 
They are retained as part of the imperfect body — a sort of " death 
in life" — and are rightly termed by the pathologist " degene- 
rate." They are generated, but not re-generated; they are 
generated in an inferior mould of form. 

Take as an example what happens sometimes to voluntary 
contractile fiber. We all know that if an animal's limbs are duly 
employed, the muscles keep up their shape and their vigorous 
power of contraction ; their tissue is of a rich bright-red color 
when the animal is fully grown, and is firm and elastic. Ex- 
amine it under a microscope, and you find it made up of even 
parallel fibers, each fiber seeming to be engraved over with deli- 
cate equidistant cross-markings, like a measuring-tape very mi- 
nutely divided. The more the muscle has been used in a well- 
nourished frame, the more closely it conforms to the typical 
specimen of the physiologist : — 

11 Use, use is life ; and he most truly lives 
Who uses best." 



32 DEATH AND LIFE. 

But suppose this muscular fiber has been unworked — suppose 
it is in the biceps of an Indian fakeer, who has fastened his arm 
upright till it has become motionless, or in the gluteus of a sol- 
dier's amputated leg, or the calf of a Chinese belle, or in a para- 
lyzed limb — then the flesh is quite different in aspect ; it is flabby 
and inelastic, of a pale-yellowish hue, and makes greasy streaks 
on the knife that cuts it. Sometimes even all traces of fibers have 
disappeared, and it is converted into an unhealthy fat. Some- 
times you may trace fibers under the microscope, but their out- 
line is bulging and irregular, the cross-markings are wanted, and 
you see instead dark, refracting globules of oily matter in them. 
In short, the muscle is degenerating into fat, retaining in a great 
measure its shape, but losing its substance. Such is, by God's 
law, the penalty of not using His gifts for four or five months. 

Now go back to our first sepulchral illustrations. M. Devergie 
found that in a period of between four and five months the flesh 
of a corpse is converted into a substance technically termed 
"adipocere:" an oleaginous substance between fat and wax — an 
artificial fat the result of chemical decomposition. What is this 
but precisely that which happens to the disused muscles in the 
cases quoted ? At the Morgue, a continuous stream of water 
washed away the fetid gases from the subject of M. Devergie's 
observations, and in the living body destructive metamorphosis 
and excretion remove the more directly noxious particles ; in 
both there remains the same oleaginous residuum. 

The instance chosen of diseased structure was purposely an 
extreme one ; but even there, a very high degree of partial death 
was seen not to be inconsistent with life. A less degree is not 
inconsistent even with active usefulness. Look at many a man 
whom his physician knows to have a weak or slightly-dilated 
heart ; he goes on with his profession, mixes in society, enjoys 
his quiet pleasures, and may even insure his life by paying an 
extra premium. Yet if an accident at any time should cut him 
off suddenly, the muscular tissue of the heart will be found pale 
and soft, while under the microscope the fibers are seen deficient 
in clear outline and in cross-markings, and exhibit here and 
there minute specks of that fatty degeneration which was so con- 



DEATH AND LIFE. 33 

spicuous to the naked eye in M. Devergie's subjects and in the com- 
pletely palsied limb. The more dilated and the more weak the 
heart, the more widespread is this degeneration. Yet enough of 
active structure is left to carry on the work of the heart, and 
perhaps to prolong life to its allotted threescore years and ten. 

A close copy of the pathological process may be made by 
soaking a piece of muscle, say from a healthy sheep's heart, in 
a running stream, in weak spirits and water, or in nitric acid and 
water, for a few weeks, when sections made from time to time 
will exhibit the several stages of fatty degeneration, from the 
minute specks in the scarcely-altered muscle up to complete con- 
version into adipocere.* 

Remark in these cases of fatty degeneration or decay that the 
substance which replaces the highly-organized animal matter is 
not utterly inorganic. It is less organized and less organizable, 
but still capable of being called alive. Of our living bodies fat 
is a part and a necessary part ; but still it is not capable of per- 
forming the highly vital duties of muscular tissue, of being as 
thoroughly alive. Degenerated products, therefore, so long as 
they form part of the body, may still be said to be alive, but less 
alive than the normal tissues they replace ; and degenerate 
growth may be justly described as " diminished life," — or in the 
words I lately used, "partial death." Degeneration, in short, 
is a more or less relapse into a lower and lower form of organic 
life, and exhibits itself therefore in a variety of grades and 
amounts. Occurring in various parts, it occasions three-quarters 
of the chronic illness which give work to the physician. 

Let it be well understood that these half-living tissues are by 
no means necessarily lessened in size. A battered and renovated 
vessel is oftener much bulkier than a strong new one ; and in the 
same way these under-nourished parts are often enlarged, and so 
have been wrongly supposed to be over-nourished. They often 
attain a most cumbersome weight and bigness without really con- 
taining tissue enough to do their work. They become, in truth, 
a foreign substance. Sometimes they acquire what seems like a 

* Figured in " Medico-Chirurgical Transactions," vol. xxxiii, plate v, in illustra- 
tion of a paper by Dr. Quain. 



34 DEATH AND LIFE. 

parasitic life, and grow as if independent of the body which they 
inhabit. Then you justly look upon them with a peculiarly un- 
favorable eye, and call them by the epithet "malignant." Can- 
cer is the best-known example to quote; and you who have 
watched its deadly quickness of growth are perhaps wondering 
that it should be put forth as an instance of lessened vitality. 
But watch further with the mind and not with the eye only ; you 
will see that its tissue never gains the higher characteristics of 
life ; it never puts on the form of the part it is planted in, nor 
performs its duties. Moreover, its half-life, so easily acquired 
and so easily multiplied, is also easily lost. Its very tendency 
to die and to ulcerate is one of the chief dangers in which it puts 
your patient. 

But we are now driven to seek our illustrations among these 
dreadful sorrows of our kind, when we can find them in less pain- 
ful scenes. Every one connects cancer and degeneration with 
death ; but perhaps it is not quite such a familiar idea to see 
partial death in a cold in the head or relaxed throat. However 
much you may smile at the notion, it is a true one ; and I should 
advise your taking the next chance which a catarrh gives you of 
seeing the truth and its bearings. It is almost worth while to 
catch one on purpose, so valuable is the lesson. And perchance 
your smile may become a grave and thoughtful one, when you 
reflect on the mysteries of life ; when you think that the slight 
inconvenience you are bearing is of the same nature as that 
which divorces soul and body, a distant and indistinct foretaste 
of that dread cup which we must all one day drain.* 

Look at your catarrhal throat in a mirror — what do you see ? 
The surface red, puffy, and with the component parts, such as 
the uvula, enlarged. There is also poured out a quantity of 
slimy material, which you well know by the name of mucus. At 
first you may be disposed to cry, " Surely here is an active busi- 
ness going on ; everything seems much more lively than usual ; 

* And perchance also this may be an useful meditation, not only for medical 
men, but also (as is remarked in an article on " The Kenewal of Life" in the 
" Medico-Chirurgical Review" for July, 1863) for amateur tamperers with life, 
who in their zeal without knowledge are so found of remedying minor bodily ills. 



DEATH AND LIFE. 35 

life is increased, not diminished." Not so fast — examine in a 
microscope a little of this mucus, and you will find it made up of 
minute balls of transparent jelly with a granular aspect, techni- 
cally called " exudation globules," " mucus globules," and "pus 
globules," floating quite free, and rolling over and over without 
any tendency to adhere together. Are these bodies a new crea- 
tion, something which an inflamed membrane can produce, while 
a healthy one lacks the power ? are they evidences of an addi- 
tional life-force ? By no means ; for they have been identified 
with those elementary forms of nascent life by which all organic 
matters grow ; they are young cells, or rather nuclei.* They are 
the form assumed by all liquid living material which under the 
influence of life is being transformed into a solid ; they are an 
infant tissue strangled in its birth. Instead of uniting into a con- 
tinuous web to clothe with epithelium the surface of the mem- 
brane, they float off helpless from deficient vitality. The business 
of mucous membranes is to be covered with epithelium, not to 
throw off mucus ; and when they are doing the latter, they are 
so far forth in a state of diminished life. 

But you may ask, what is that redness and that throbbing of 
the inflamed part ? do not they show an increased circulation of 
the vital fluid, and therefore increased life ? Quite the contrary, 
for the membrane is red because its blood-vessels are relaxed and 
dilated from loss of vital elasticity ; the blood sticks in them as 
water in a bulged pipe ; and the arteries, pressed upon from be- 
hind by the heart, throb because the obstruction impedes their 
action. 

"But the pain, — does not that show that the vital power of 
sensibility is increased ? I cannot, in general, feel that I have 
got a throat ; and now I am reminded most disagreeably of the 
fact." No ; pain does not indicate an increase of proper sensi- 
bility ; in this case it is associated with a very marked decrease. 
During your catarrh the lining membrane of the fauces loses its 

* The identification of young epithelium and pus cells, was some years ago 
amusingly made out by M. Lebert, who, in plate iii, figs. 3 and 6, of the atlas to 
his "Physiologie Pathologique," places them in opposition, with the intent of 
pointing out their differences, but with the result of showing their identity. 



36 DEATH AND LIFE. 

delicate appreciation of flavors- — everything is equally nasty, 
unless there is a pungency in it too powerful to be pleasant to the 
healthy taste. And it is wanting also in common sensibility ; for 
it does not distinguish the shape or size of morsels swallowed, 
all of which feel equally large and awkward. 

Or you may get a whitlow on your finger, or a boil, and study 
how the nail is stayed in its growth, and the skin is killed ; while 
the materials intended to renew them are checked in their de- 
velopment, and go to be deposited as pus, a concentrated form 
of half- vitalized fluid, very similar in every respect to mucus.* 
And, like your catarrhal throat, your inflamed finger-tip is want- 
ing in sensibility : try it, and you will find for any delicate work, 
such as feeling the fine lines of a copper-plate, or the flaws in a 
polished surface, it fails in its duty. Pain, in short, is the brothe r 
of death ; a painful part is never performing its whole vital func- 
tions — it is partially defunct. 

The same partial death, which has been hitherto described as 
constituting the various diseased states of the solid structures of 
the body, may also attack the fluids; and in them, as in the solids, 
it may show itself either as a destructive relapse into a less 
organic life, or as an arrest of development. The poison of fever, 
for example, destroys and renders useless as nutriment some 
constituents of the blood ; the insufficient blood is circulated to 
all parts of the body, causing, not local pain, but general malaise 
by its deficient vitality. The half-poisoned tissues allow the 
poisoned material to ooze through them, causing diarrhoeas, ex- 
halations of blood from mucous surfaces, purple blotches on the 
skin, and a general staining of the whole body of a dusky hue. 
If the quantity of blood poisoned is moderate, it can be easily 
spared ; it is carried off gradually by excretions, and its place is 
filled up in time by new blood. But if the rare case happens of 
so much being poisoned at once that too little remains to earry 
on the business of the body, then death occurs by sudden shock ; 
or if, through ignorance, carelessness, or false theory, there is an 

* On the pus formation in connective tissue, see Virchow's " Cellular Pathol- 
ogy," fig. 137, and text adjoining, and the Lumleian lectures which follow in 
this present volume. 



DEATH AND LIFE. 37 

insufficient supply of material to take the place of the killed 
blood, the vitality wanes away more slowly. And as its loss oc- 
curs more slowly, some one part more than another is usually 
affected; there is congestion and inflammation — that is, local 
death — of the digestive viscera, or of the lungs, or of the brain, 
and the patient's disease is allotted by name to that last cause. 
And thus in fever, the blood relapses into a less organic form 
through its vitality being destroyed by a morbid poison. 

Let us next look for an instance of imperfect life in the blood 
occasioned by arrest of development. You are all practically 
familiar with the condition, so common among hospital out- 
patients, which you have already learnt to call anaemia. The 
word means literally " bloodlessness," but in reality relates 
rather to deficient quality than deficient quantity. The circulat- 
ing fluid cannot but fill the hollow vessels which hold it, but it is 
wanting in the most highly organized, the most truly living of 
its constituents. It is pale, from the diminished numbers of 
those floating red globules which give it florid hue. This capital 
of red globules is by far the most important portion of the blood ; 
so much so, that it may be taken as a direct measure of corporeal 
and mental vigor ; a man has a larger proportion than a woman, 
a strong man than a weak man, an adult more than a youth or 
an elder, a patient after recovery more than during his sickness 
of whatever kind, a horse in high condition more than when 
brought up from grass. Yet in spite of this importance, we find 
to our surprise that this floating capital may be largely en- 
croached upon without a bankruptcy. For example, Dr. Andral 
has analyzed the blood of a patient with anaemia, where the blood- 
globules amounted to less than 89 parts in 1000, whereas their 
natural proportion should be at least 120 parts in 1000. More 
than two-thirds of this constituent were missing ! And yet the 
patient was living and moving, and very likely quite recovered 
in the end if rational treatment was adopted. Now, in pure 
anaemia there is not found any degenerated devitalized substance ; 
the missing globules have not relapsed into a lower life, so that 
their ruins or debris should constitute a foreign morbid matter ; 
they have been used up in the regular way, and have supplied 



38 DEATH AND LIFE. 

materials for the tissues, as they are moulted off from day to 
day ; while at the same time there has been a want of renewal, 
an arrest of that continuous development of blood, which is 
necessary to complete life. 

Pure anaemia has been spoken of; but, as might have been 
expected, this defective supply of the materials of growth much 
weakens the vitality of many of the manufacturing and excreting 
viscera : for their machinery needs continual repair, as much as 
any part of the voluntary apparatus. Hence, in cases of ansemia 
we often find that the liver is not so lively as it should be, and 
some of the color it ought to get rid of stays in the circulation, 
or exudes and chronically stains the skin of a bilious hue. Or 
perhaps the kidneys do only half work, and the urea which they 
ought to drain off is retained, causing very serious derangements 
of health. Thus there is a mixed pathology in these cases, a com- 
bination of arrested life with a relapse into a lower life ; the life 
of the specially affected organ is diminished, and it leaves behind 
in the system substances of inferior vitality which its proper 
business is to excrete or separate. 

Or again, ansemia may so lower the creative power of the 
blood, that instead of the body being built of elastic and highly 
vitalized fibrin, it has to put up with a cheesy, brittle substance 
called tubercle. This is just the sort of fraud a rascally contrac- 
tor commits, when he lays your floors on half-seasoned timbers. 
Your house is destroyed by dry-rot ; and the lungs in which 
tubercle has been substituted for healthy connective tissue gradu- 
ally soften and break up. The most effectual remedy in both 
instances is to look after the builders, to secure the honesty of 
the one and the vitality of the other as far as possible. 

When the various accidental circumstances of our daily habits 
dispose various parts of the body to even the few elementary 
forms of disease which I have mentioned here, a great variety of 
abnormal phenomena may be produced. Our body is a harp of 
so many strings, that all sorts of discords may arise out of its 
combinations.* These discords have received much attention 

* " Strange that a harp of thousand strings 
Should keep in tune so long." — Watts. 



DEATH AND LIFE. 30 

from minds with a taste for order ; they have been classified 
into groups ; and if, unfortunately, the orderly mind was afflicted 
with a theory, sadly have facts sometimes suffered by the Pro- 
crustean bed of a Nosology, into which they have been forced. 
On the whole the nosologists (NoooXo-yoi — people who talk about 
diseases) have been convenient, for their nomenclature often 
helps us to describe in one word what otherwise would want a 
parenthesis. But they have been a convenient evil, and their 
labors have had this bad result ; they have attributed a positive 
existence to that which in reality is a negation. " A Disease," 
under their manipulation, instead of being a mode in which life 
is deficient, becomes an actual motive power ; the giving it a 
generic and specific name links it in our minds with the subjects 
of a naturalist's studies, and we get to clothe it in individual 
characteristics, and to assign to it individual actions. The con- 
sequences in science have been most fatal to true progress. It 
has had upon the art of medicine just the effect that would be 
wrought upon Optics by regarding a shadow as a material object 
instead of an absence of light, upon physics in general by ac- 
counting cold instead of heat as the active agent. The main hope 
for bringing Therapeutics up to the level of modern science lies 
in discarding at once and forever this traditional notion. 

I am glad to say less practical harm than might have been 
feared has been done by these false notions. In the first -place, 
man's body is tougher than usually thought, and will stand a 
great deal of wrong treatment ; and, secondly, experience has 
somewhat checked the bold hand of a relentless adhesion to 
theory. Still, it can hardly be doubted that the increased chance 
of cure under professional treatment has not been so much as 
might have been expected from the advance of general knowledge. 

Of late medical art, as far as practice is concerned, has been 
turning over a new leaf; nosologists are of less repute, and at 
last, under the influence of common sense, attention seems di- 
rected to the maintenance of life in the body more than to the 
expulsion of death out of it. Such is the true preaching to the 
sober mind of the new modes of treatment which, without falling 
in with the dogmas of any particular "pathy" have yet been 



40 DEATH AND LIFE. 

silently adopted by the rational adherents of each within the last 
few years. I may instance the care bestowed upon the selection 
of alimentary substances ; the use of water, of oxygen, of iron, 
of animal oils, of chlorine, of soda in doses more like a food than 
a drug, of lactic and other organic acids, of salts of phosphorus 
and lime, of sulphur, ammonia, bile, pepsin, and several other 
agents established by common consent without being suggested 
by any previous theory of therapeutics, or traditional rules of 
the medical art. These are constituents of the animal frame, and 
are administered and trusted to as filling up an obvious void. 

If experience has taught us to reform our practice, should it 
not teach us to reform our theory too ? that so the partial ad- 
vantages which have been gained might become universal, and 
our words and acts might cease to be inharmonious. 

I began this lecture by likening the animal body to a building 
constructed of perishable materials, which need continuous re- 
newal to maintain the usefulness of the structure. To keep up 
the simile, the permanent architect is the indwelling life, and he 
best performs his duty, not by fits and starts of work, but by 
ever-watchful industry. He should be every moment removing 
decaying materials from the walls and working machinery to be 
carted away at convenient periods, and he should be every mo- 
ment supplying their place by fresh. Thus there are two depart- 
ments carried on simultaneously — the "destructive" and "con- 
structive ;" and upon their harmony and completeness depend 
the perfection of life which we call health. Both are necessary ; 
and the deficiency of either or both, or the preponderance of one 
over the other in various parts, or their deficiency in one part 
while other parts remain active, constitutes a deficiency of life — 
a disease. 

This deficiency the physician is called upon to remedy ; and it 
is of the utmost importance to his usefulness that he should re- 
cognize that it is a deficiency, and act upon the recognition. He 
must look at his pharmacopoeia with this thought constantly 
present before him, with an eye to the ultimate benefit of the 
patient, to a goal beyond that of the immediate effects. He 
should make his chief thought how each of the reagents employed 



DEATH AND LIFE. 41 

will finally touch life ; whether they are calculated to add to or 
diminish the vital functions, to add to or diminish the vitalized 
substance of which his patient is made — whether by temporarily 
diminishing the functions or substance he may not remove an 
impediment to their balanced actions, so as to lead to a final in- 
crease — or whether this artificial diminution of functions or sub- 
stance may not become permanent, and inflict permanent injury 
on his patient. This final goal of life renewal must be consciously 
or unconsciously in the heart of the physician, or in the heart of 
his guides ; otherwise I am sure he contributes more to the ill 
health than to the good health of mankind. 



LECTURE II. 

DISEASE AND CURE. 

What is cure ? — Classification of disease, for therapeutical pur- 
poses, into deficiencies of growth and deficiencies of moult- 
ing — Deficiencies of growth from Chossat's observations — 
Analogous natural states in disease— Deficiencies of moult- 
ing — True and apparent— Mixed lesions — Natural cure and 
artificial cure — Cure originated by the healthy parts of the 
body — Classification of means of cure — Constructives — De- 
structives — Arresters of construction — Arresters of destruc- 
1 tion. 

(Introductory, St. Mary's, October 5, 1863.) 

You are entering the hospital wards to study Disease — that 
fitful twilight coming between the glad radiance of life we call 
health, and death, the drear darkness of its departure. You see 
the gloom sometimes irrevocably deepen, more often melt back 
again into the beams of returning day; and you would fain learn 
how to aid this joyful event which we hail as cure. To minister 
to it is to be the business of your lives ; and therefore time can- 
not be wasted in first thoughtfully considering what it is. 

Healthy life consists in a continuous and equally balanced 
repetition of the two necessary parts of the renewal of the body, 
constructive and destructive assimilation, in other words, " grow- 
ing and moulting." The essential nature of disease, that which 
makes it disease, is a deficiency of health, a deficiency of either 
construction or destruction in one or more points. The cure of 



DISEASE AND CURE. 43 

disease, natural or artificial, consists in a new birth or renewal 
of the deficient life. 

The practitioner, to whose mind the cure should be the ever- 
present object, will therefore do well to classify as far as he can 
all morbid phenomena on this principle ; for on this principle 
will be based his most successful practice. 

Do not suppose that I am here condemning or proposing to 
reform the existing nosology of statisticians. Every classification 
must be constructed for a specific purpose ; it can be complete, 
and its classes be prevented from overlapping, only by that one 
specific purpose being adhered to. The hospital porter divides 
diseases into those of males and those of females, and subdivides 
these again into medical and surgical. An officer of health di- 
vides them into epidemic, endemic, enthetic, sporadic, fee. ; a 
philanthropist according to their causation by various occupa- 
tions, as diseases of painters, clergymen, coppersmiths, chimney- 
sweeps, &c. An anatomist arranges them "a capite a calcem" 
(as Morgagni says he does), according to the part affected. A 
pathologist aims high at a kind of natural system, and classes 
together those phenomena whose essential nature, whose morbid 
processes seem alike ; for him diseases are primarily divided into 
zymotic, tubercular, cancerous, hsemorrhagic, catarrhal, arthritic, 
&c. The Registrar-General, who has to provide a single nomen- 
clature for a great variety of temporary purposes, and suited to 
a great variety of minds, wisely contents himself with a very 
imperfect and illogical classification as a gradual stepping-stone 
to a better. For nomenclature the best working classification is 
the one which contains the greatest quantity of well-known 
names, and for common purposes that which is most common. 

But this classification is most faulty when applied to aid us in 
therapeutics. To make it our only classification is to introduce 
an arbitrary method into the treatment of disease which cannot 
but impede all true progress, not only in the mind of the indi- 
vidual practitioner, but of the art itself.* However, our pos- 

* The danger is clearly pointed out in the " London Medical Review" for 
March, 1863. " The dictionaries and encyclopaedias of medicine, useful as store- 
houses of facts, have done much to perpetuate this error with the unthinking 



44 DISEASE AND CURE. 

session of it and use of it for its intended purposes, does not 
preclude special classifications for special objects ; and, indeed, 
the more ways a man has of classifying a subject the more he 
will know about it, and the more ready he will be with his knowl- 
edge. 

I shall, therefore, not hesitate to recommend for therapeutical 
purposes an attempt to classify morbid phenomena after a fashion 
which I confess would be inconvenient, if not impossible, to apply 
to them for other objects. 

Life we know to be a state of unending change ; and this 
change is double — constructive of the body from foreign ma- 
terials, and destructive of it into inorganic elements. The phy- 
sician, then, in his ministry of the living body, has to be always 
dealing with construction or destruction, or both together ; and 
it must make a great deal of difference for him to be able to re- 
cognize which part of life he is dealing with ; because the instru- 
ments he employs to modify these opposite parts of life must be 
in some way of opposite natures. 

Therefore I cannot but think we should be contributing very 
much to our practical usefulness, if we tried habitually to divide 
morbid phenomena into (1) Deficiencies of nutrition or construc- 
tive form-building, and (2) Deficiencies of moulting or form- 
destruction. 

We should thus have ready to hand a decisive spur to a definite 
course of treatment in all cases ; whatever empirical or tradi- 
tional means we adopt would be under the control of a final prin- 
ciple, and we should feel quite sure that we were at all events 
aiming at a rational end.* 

portion of our fraternity. "With many even at the present day a sick person is 
regarded as a sort of living conundrum to which there is but one correct solu- 
tion — a Greek or Latin word indicating his disease. When this is guessed, the 
word is as it were ' looked out' in a sort of mental dictionary where the practi- 
tioner finds against it appropriate treatment according to his lights. The arbi- 
trary practice thus induced strongly resembles the child's idea of coloring a 
printed sketch — this is a tree, and therefore it must be green ; sky. blue of course ; 
water, ditto; glass, ditto; a road, burnt sienna." There are some excellent re- 
marks on classification in the preface to Dr. Reynolds' volume on Epilepsy. 
* In my systematic lectures on the practice of medicine I have been used for 



DISEASE AND CURE. 



45 



But is it possible to make this division ? Much more possible 
than appears at first glance, if we will first consent to clear our 
minds of nosological prejudices begotten of old theories, and 
come to the task fresh and unfettered, ready to accept all the 
conclusions which independent observation may supply. I will 
point out a few of the more obvious sources of knowledge which 
may help us to the required end. 



First, for deficiencies of nutrition or form-building. 

The morbid phenomena capable of being classed under this 
head are doubtless to be found most purely displayed by starva- 
tion and loss of blood in otherwise healthy bodies. The labors 
of M. Chossat and Dr. Marshall Hall have almost exhausted 
these subjects, and are easily accessible to all. 

the last ten years to adopt a classification similar to this in the first part of the 
course, which includes general pathology, and consequently the principles of 
therapeutics. 

f Of whole of blood — Haemorrhage, 

transudation. 
\ Of part of blood— Serous dis- 
charges, sero-fibrinous ditto, 
I anaemic, albuminuria, &c. 
{ Uraemia, asphyxia, jaundice, lithic 



Loss of normal constit- 
uents 



Morbid Changes 
in Fluids . . . 



Abnormal retention of 



excretions 



I 



Foreign additions 



acid and oxalic acid diathesis, 
&c. 
t 1. Common poisons. 
\ 2. Morbid poisons. 
C (1.) Of blastemas — Mucus, pus, 
tubercle. 
(2.) Of cartilage-cells — Cancer and 

some other tumors. 
(3.) Of white fibrous tissue — Cir- 
rhosis, false membranes, gra- 
nular kidneys, contracting 
scars, &c. 
Retrograde change into less vital tissue, or degenerations, 
fibrinous, waxy, fatty, chalky, 
or mineral, &c. 
[ Foreign additions .... Parasites. 
In the second part of the course these changes are arranged anatomically. 



Morbid Changes 
in Solids . . . 



Arrests of development 
into normal tissue . . 



46 DISEASE AND CURE. 

We find fully established by M. Chossat's* rigorous experi- 
ments on healthy animals certain phenomena as resulting from 
the deprivation of food, and therefore as resulting from the ar- 
rest of continuous growth by the want of its material. They 
are as evidently phenomena of innutrition as the ruin of an un- 
repaired building is a phenomenon of the want of bricks. 

Prominent among these phenomena we find — 

1. Collections of fluid in the serous sacs (p. 73). 

2. (Edema of the extremities (p. 82). 

3. Softening and destruction of the mucous membranes (p. 85). 

4. Thickening of the epithelium in other parts (p. 86). 

5. Blackening of the viscera, especially the liver ; and red- 
dening (? with hsematine) of the secretions, at least of the bile 
(p. 74). Sometimes the substitution of brownish-red congestion 
for the black (p. 74). 

6. Bluish, livid, yellow, whitish and reddish stains during life 
in the transparent parts of the skin (p. 73). 

7. Loss of weight, producing death when it amounts to t 4 q- of 
the normal weight (p. 21). 

8. Hectic fever. That is to say, very marked oscillations of 
the diurnal variations of temperature (p. 123). 

9. A continuous decrease in the power of the body to resist 
cold (p. 132). 

10. At first a scanty excretion of dry, bilious, grass-green 
fgeces, and afterward diarrhoea of liquid saline matter (p. 151). 

11. Excitability of involuntary muscular fibers by stimuli. 
Even after death the auricles of the heart of starved animals re- 
tained for an unwonted length of time their contractility on being 
touched (p. 150). 

12. Convulsions, similar to those in death by haemorrhage 
(p. 187). The convulsions were often opisthotonic. 

13. In comparing the losses of substance in the different 
tissues of starved animals, the nervous system appeared to have 
suffered least, and indeed retained nearly its full weight after 

* " Kecherches experimentales sur l'inanition." Paris, 1843. 



DISEASE AND CURE. 47 

death. This and the former observations seem to point it out as 
the true ultimwm moriens in such circumstances (p. 91). 

Here are a collection of phenomena which we are daily wit- 
nessing in our patients, modified of course by the fact that in 
them usually the defect in the supply of materials of growth is 
but partial. Shall we be wrong in attributing such phenomena 
to innutrition? Still more, shall we be wrong in treating them 
as innutrition ? 

I will allude to a few of the cases in which you see these 
phenomena as the result of the imperfect vitality we call disease, 
referring by a corresponding numeral to similar phenomena 
intentionally produced by starvation in M. Chossat's experi- 
ments. 

1. The conventional term " effusion" applied to dropsies of 
the serous sacs is misleading to students. They are apt to fancy 
it an active process, in which the inconvenience arises from the 
membrane "effusing" too much fluid, and their minds are im- 
mediately directed to the necessity of checking this imaginary 
activity ; whereas in reality the membrane need not pour out 
more than it does in health, nay, it may pour out much less than 
it does in health, and yet dropsy very rapidly take place by the 
arrest of absorption ; and it is from this arrest of absorption in 
consequence of generally diminished vitality that collections (as 
they should be called rather than " effusions") of fluid take place 
in the pleural, peritoneal, and pericardial sacs.* You find them 
in anaemia, hydremia, uraemia, leucocythaemia, and other con- 
ditions yet unnamed, f where the blood in the diminished propor- 
tion of its chief vital constituent of red globules typically repre- 
sents in common parlance the generally diminished vitality of the 
whole body. From the diminished consistence of the circulating 
fluid the endosmose inward of liquids, that is, absorption, is 
diminished according to the well-known law of transfusion. 

* See Lecture XVII of this volume, on hydrothorax. 

f It must not be supposed that nosologies contain a name for every possible 
morbid state : many, by no means uncommon, can be described only by a peri- 
phrasis, simply because nobody has taken them up in special — carent quia vate 



48 DISEASE AND CURE. 

Again, these collections of fluid arise wherever the circulation 
is arrested by mechanical impediments, as in cardiac or hepatic 
disease for example. Here comes into play another law of 
diosmose, namely, that in the case of a moving liquid it takes 
place in a direct ratio to the quickness of the motion. The more 
the circulation is slackened the more obstinate the dropsy is, and 
increasing its living force and freedom cures the patient. 

If we cannot detect any of these explicable organic modes of 
dropsy's origin, it is still surely philosophical to conclude that a 
similiar agency, a similar deficiency of life is acting throughout. 

2. The remarks I have made apply equally well to anasarca, 
which is a collection of fluid in the minute sacs of the areolar 
tissue, instead of the large serous sacs. 

3 and 4. It is most interesting to find morbid states of the 
mucous membrane characterized by softening and destruction, 
and also by thickening, produced as the direct result of inanition. 
How apt we have been to look upon this changed form of vitality 
and this accumulation of semi-vitalized substance as evidence of 
activity ! how apt we have been to reduce the vitality in our aims 
at cure ! I need hardly allude to ulcerations and rugged condi- 
tions of the stomach, of the throat, of the vagina, and neck of 
the womb, which have been treated to their great injury by 
depressing medicines. 

5. We are very much inclined from ancient prejudices to take 
congestion for a proof of active life, and the red, black, or other 
dark-colored relics of congestion, as post-mortal evidences of 
activity in the organ so discolored. It appears to indicate the 
direct contrary. 

6. So also with livid and reddish discolorations of the living 
skin. How often do you hear it remarked that a red, bloated- 
faced man wants "bringing down," when, in fact, what is re- 
quired is a more vitalized blood, and a more vigorous action of 
the heart and arteries. How often is a patient drenched with 
mercurials and purgatives because he is " black under the eyes," 
when tonics and bitter diet are the true specifics. Blueness and 
blackness of the sclerotic, again, is a safe indication for tonics, 
and the finger nails may also be used as a guide to the same 
treatment. 



DISEASE AND CURE. 49 

7. The regularity with which death results on the loss of a 
certain amount of weight should lead us to make more use than 
we do of the balance, that easily applied aid to diagnosis, prog- 
nosis, and treatment. It is a direct measure of the success of 
our medicines, or of the progress of disease. 

8. Hectic fever is an obscure subject. But I think some 
approach to an elucidation of it may be made from the direc- 
tion of those singular nycthemeral oscillations of temperature 
which take place in health. In full vigor, the normal produc- 
tion of animal heat rises gradually up to its maximum at noon, 
and falls to its minimum at midnight. In health this variation 
is slight, but in the simple debility produced by deficient food it 
is more than quadrupled. In M. Chossat's experiments it rose 
from 0*74° to 3-28°. The extreme of heat was so much more, 
and the extreme of cold was so much more than in health ; and 
not only was this change observed, but also that the periods of 
the accession and diminution became irregular, and were not 
governed by the diurnal time. Do not these observations dis- 
tinctly associate periodic fevers, and through them perhaps the 
periodicities of disease, with direct debility? 

9. The liability to be injuriously affected by external agents, 
especially by cold, is a sure proof of deficient vitality. This, 
in our patients, is not always accompanied by sensitiveness to 
the changed temperature, but is made evident by catarrhs, 
bilious attacks, local inflammations, congestions, &c, and is 
often popularly rated as characteristic of "an inflammatory 
subject." 

10. M. Chossat's observations of the alvine evacuations are 
very valuable. Let us never forget that not only constipation, 
but also diarrhoea and an exceedingly foul condition of the ex- 
cretions, may, and in fact generally do, arise from mere inani- 
tion. This is an important lesson for routine adherents of blue 
pill, gray powder, and black dose. 

The commonest instance we have of fetid evacuations from 
inanition is that of unfortunate babies who have been starved 
by hand-feeding, or the imperfect condition of their mother's 
milk. Doubtless mercury will make the stools less disagreeable, 



50 DISEASE AND CURE. 

for it throws into the bowels a quantity of bile, which prevents 
their decomposition, but that is done at the expense of the poor 
infant's body, and the patient is sacrificed to save our noses or 
our theories. 

11. The weaker the life the quicker the heart beats, and the 
readier it is excited. This phenomenon is particularly well 
marked in zymotic fevers, where the rapidity of the pulse is 
a good guide to the degree in which the poison of the fever has 
affected the system, and what force the system has to bear up 
against the poison. In pneumonia, too, the rapidity of the 
pulse is usually in a direct ratio to the danger, and to the ne- 
cessity for opiates and stimulants. In pulmonary consumption, 
starving, depressants, expectorants, salines, and all that is usu- 
ally classed as antiphlogistic treatment, makes the pulse quicker 
and quicker, and nothing reduces it so steadily as oil and other 
restoratives. 

12. The knowledge that convulsion arises when there is a 
deficient supply of blood to the brain, has been a long time in 
forcing upon the profession the conviction that it is a disease of 
inanition. Perhaps the impediment has been the finding in post- 
mortem examinations black blood, rendering abnormally conspic- 
uous the smaller vessels and capillaries, when, in certain diseases, 
convulsions have preceded death. The blood is too visible, and 
so the fallacy has been jumped to that it is too abundant. The 
real fact is, that it is too stagnant, that it is too arterial, too 
little renewed. Perhaps the great show that convulsions make, 
the natural awe which they excite among the by-standers, and 
the active help they seem to call for, impress us with an idea of 
activity of life in the sufferer. Chorea, epilepsy, teething fits, 
convulsive apoplexy, delirium tremens, hysteria, and some forms 
of mania are familiar instances. But in all of these every ex- 
perimental improvement made from year to year in the treatment 
is in the direction of replacing lost nervous power, not of re- 
straining its excess. 

13. The difficulty which the nervous tissue exhibits in parting 
with its substance by vital decay, explains the difficulty of its 
renewal. There are no patients so slow in recovering health as 



DISEASE AND CURE. 51 

those whose nervous system is exhausted. They are months or 
years in getting ill perhaps, and they are months or years in 
getting well. Let our recollection of the slow growth of this 
tissue comfort us under such circumstances. The time and com- 
pulsory idleness needful for its restoration make it the most 
expensive of tissues to get worn out, and rightly enough its 
higher manifestations are most highly paid for. 

Among diseases of deficient construction may also be included 
the tissue diseases of degeneration, where instead of highly vital- 
ized elastic material a brittle, or a soft, or a formless mass is 
deposited. It is alive, but imperfectly alive, easily dies, and is 
useless while it lives. Tubercle is a substance of this sort. 

It appears strange at first glance that some organic matters 
which are referable to this class should carry out of the system 
with them a spark of half independent vitality. Cancer, for 
example, multiplies itself conspicuously, and so does pus in a 
more hidden manner, so long as they can get their food from 
the body. But this multiplication is the lowest (one might say 
the most diluted) form of life, and certainly indicates no redund- 
ancy in the parent system. 

M. Chossat remarks, "Bichat and the physiologists who have 
been occupied on the same subject before and after him have 
thrown the greatest light upon the causes of death, by classify- 
ing them according to the functions which help to bring them 
on. In dividing death into death by the brain, death by the 
lungs, and death by the heart, they run through the series of 
vital functions, and suppose that they have thus exhausted the 
subject. However, on coming to facts, it is certain that we 
thus explain but a small number of the cases of death, and that 
the great majority of those brought under our observation escape 
this classification. This is so even in the cases which seem easiest 
to lend themselves to this division. In pulmonary consumption, 
for instance, who can say that usually death supervenes by as- 
phyxia? for the lung on the day of decease is not, as a rule, 
more disorganized than it was the day before; and yet the day 
before it sufficed for the aeration of the blood. On the other 
hand, who has not witnessed autopsies in a number of febrile 



52 DISEASE AND CURE. 

maladies, in which there is no morbid change found, except le- 
sions, often very insignificant, in the intestinal canal? One can- 
not, without doing violence to the judgment, consider these as 
sufficient to account for the death. The fact is, the classification 
of Bichat does not explain all, and to the three modes of death 
which he points out we must needs add at least a fourth — death 
by the digestive apparatus, or inanition."* 

M. Chossat is quite right; indeed he rather underestimates 
his case: very much more than half the patients we lose die 
from imperfect nutrition, and very much more than half of those 
who recover gain that end by chanced or designed restoration 
of their digestive functions. 

Exactly the same means that prevent death, prevent or cure 
disease. This may seem a platitude, but it is a very important 
one, and must not be allowed to "lie bed-ridden in the dormitory 
of the soul" because it is so true. We are all ready enough to 
admit that when a patient is in danger, the first thing to be done 
is to keep him alive. Let us act in the same way when he is not 
in danger ; cure him by keeping up the partially or locally fail- 
ing life. Postpone partial death, as you would postpone total 
death. 

(ii.) 

Disease of destruction, or deficient moulting, arises when the 
functions whose business it is to remove effete products from the 
tissues are inefficient. I say " functions" designedly instead of 
organs, in order to include the whole process from the period 
when the tissue becomes effete to the expulsion of the products 
of its decay from the body. For in whatever part of the process 
m check takes place, the result on the whole health is identical, 
and the principles, though not perhaps all the details, of the 
treatment must be the same. And in whatever part a check 
takes place, the main injury is the stoppage of vital metamor- 
phosis at its origin. 

This is the case even in mere mechanical obstruction. Take 

* Pao-e 194. 



DISEASE AND CURE. 53 

for instance the impaction of a gall-stone in the common duct ; 
first, the intestines are in want of bile — that is a deficiency they 
can easily bear ; then the gall-bladder and ducts get distended — 
which does not interfere very much with the patient's comfort ; 
but the real serious injury is the non-removal from the blood and 
tissues of what forms the biliary secretion. And the injury is of 
exactly the same nature, whether the jaundice arises in the me- 
chanical way alluded to, or whether it arises in the ultimate 
tissues themselves, as jaundice from mental impression for ex- 
ample. 

It might seem at first sight as if diseases of deficient moulting 
were exceedingly easy to detect, and to reduce to classification. 
We are in a position to measure accurately the quantity and 
quality of the most important excretions, and can approximate 
to a knowledge of those not so readily reckoned. We can know 
by experiment the daily excretion of urea, phosphoric acid, sul- 
phuric acid, and water by the kidneys ; of carbonic acid by the 
lungs ; of faeces by the bowels ; of water and salts by the skin, 
and we can find out with a fair approach to accuracy when these 
are diminished. But in the great majority of cases this diminu- 
tion is in reality the consequence of deficient supply : vital decay 
does not remove the tissues, because there is no new material to 
take their place. To call these cases instances of deficient 
moulting is a misappropriation of terms, and to treat them as 
such most pernicious. 

The most familiar example is the amenorrhoea of weakly 
females. To what purpose are emmenagogues ? Why should 
we wish to force the ovaries or uterus to bleed, when the reason 
why they do not bleed is that there is not enough blood formed ? 
The custom of administering purgatives, whenever the bowels 
are not open so often as those of robust persons, is another too 
familiar instance of mistaking the true nature of the deficiency. 

The only diseases we can safely refer to the class now con- 
sidered are those where the effete product is obviously retained 
in excess in the system, and where the impediment to its excre- 
tion is usually the imperfect action of the secerning organ, such 
as uraemia or the excess of urea in the blood from degenerated 



54 DISEASE AND CURE. 

kidneys, asphyxia or retention of carbonic acid from non-aeration, 
jaundice from mechanical impediment, or incomplete develop- 
ment of hepatic cells, and perhaps certain cases of the lithic acid 
diathesis. 

In most of the patients we have to do with, both classes of 
morbid phenomena are united ; there is a general deficiency of 
life, and both nutrition and destruction are below par, often in 
equal, more often in unequal proportions. The instance I have 
just given of uraemia is in point ; one marked change in the blood 
is the retention in it of urea, the product of destructive meta- 
morphosis, which acts as a poison ; but another change, certainly 
more worthy of consideration as being more under our eontrol, 
is the absence of red blood-discs by reason of defective nutrition. 
Hence we have mixed phenomena from the union of the two. 

I would say incidentally that there are few cases in which the 
defective nutrition is not at the same time the most important in 
a pathological sense as explaining natural phenomena, and at the 
same time the most important in a therapeutical sense, as being 
the most easily compensated. 

Be it remarked also that mixed phenomena, requiring mixed 
treatment, arise sometimes from the deficiency in one part of the 
chain of vital acts overthrowing the balance of functions found 
in health. An apparent excess of certain functions or constituents 
arises from the absence of those which normally are in corre- 
spondence with them. Thus Dr. Prout, to whom the pathology 
of urinary diseases owes so much, speaks of a " phosphatic 
diathesis," and we not uncommonly hear medical men speak of 
" phosphatic urine," as if the ailment were an excess of the salts 
of phosphorus ; although in reality in such cases those constitu- 
ents of the excretion are usually less copious than in health, and 
are deposited only from deficiency of the acid which should hold 
them in solution. 

The object of medical treatment is cure. The end of the 
physician's labor and care is accomplished by the patient getting 
well. What is this cure or getting well? It is a restoration of 
the disordered body to its natural state of ease or health. 



DISEASE AND CURE. 55 

This restoration we often see come to pass independent of any 
interference from without, by what is allegorically called an 
" effort of nature." Wounds heal, diseases cease, in men and 
animals who have none to help them. The event comes about, 
not in consequence of the driving out of any materies morbi, but 
on the resumption of their normal functions by the diseased 
organs : the full vital force regains its influence in them, and 
they recover. The social disease of a " strike" is cured by the 
hands going on work again. 

Now diseased organs must necessarily have less power in them 
than healthy ones ; and it is obvious therefore that the curative 
vitality must mainly be due to, and proceed from, those which 
remain healthy. It is to their having some sound action to spare 
that the sick man owes his recovery. The vital force at the same 
time removes the retained products from the tissues, and replaces 
them by new material. This is the true teaching of nature's 
cure. 

Cures by art are effected in exactly the same way. Every 
artificial appliance which does not aid this one only mode of re- 
covery is an impediment to it, or simply a nullity. A drug in 
itself effects nothing by its mere chemical or neutralizing in- 
fluence ; it is the vital power which this drug calls forth, or frees 
from a burden, that is the true healer. Quinine, for instance, 
will not neutralize malarious poison ; Peruvian marshes are not 
less deadly for cinchona trees falling into them ; but the drug's 
vital action on that which remains healthy of the body cuts short 
the fever which is the consequence of that malarious poison. The 
action of a remedy by which a sick body becomes sound must be 
looked upon as a vital act of the body itself and not a simple act, 
but a series of vital acts, which grow out of one another in regu- 
lar succession as the branches grow from a tree. They are not 
dependent upon the continuous presence of the remedy, but 
persist long after it is removed from the system, just as a rail- 
way train goes on "of itself" (as we conventionally say) when 
disconnected from the locomotive. The true art of healing; con- 
sists in the establishment of vital acts tending toward the re- 
newal of the body, toward a new birth of deceased tissue, and in 



56 DISEASE AND CURE. 

the encouragement and aiding of those vital acts after the re- 
moval of their original excitant. 

Since there are two parts in the chain of life, " construction" 
and "destruction," and since external agencies may act upon 
these in two ways by increasing them or diminishing them, a 
primary fourfold classification of curative agents naturally arises ; 
and this will be the most handy classification for a practical man. 

We have — 

(1.) Constrictives (uarorpo^iKa) or aids to formative nutrition. 

(2.) Destructives (Wo;u>™<a)' or augmenters of destructive 
assimilation. 

(3.) Arresters of construction (piofcafievruca). 

(4.) Arresters of destruction (Pio^vUktiko). 

Among Constructives we have the following classes : — 

1st. The materials of ivhich the body is built up : albumen, 
fibrine, gelatine, fat, oil, water, iron, lime, phosphatic salts, soda, 
ammonia, sulphur, oxygen, $c, which are generally taken in the 
form of food. 

2d. Medicines which appear to act by replacing necessary 
constituents of the body. — -This is as yet a very dimly under- 
stood class ; but we may hope something from the progress of 
physiological chemistry to explain the action of sundry medi- 
cines, which we cannot doubt will be proved restoratives, though 
we cannot at present see by what steps. Quina and other vege- 
table alkaloids may be taken as an example, whose cure of ague 
may be best explained by supposing them to replace some con- 
stituents of the body destroyed by malaria. 

3d. Digestive solvents. — Water, which must be in excess of 
that required in the structure of tissues, and without which the 
said materials cannot be absorbed. Carbonic acid — required to 
be present in the water for the easier solution of bone, earth, 
carbonate of lime, and albuminous food .which contains them. 
Pepsine, to replace deficient gastric juice. Lactic acid — required 
in the stomach to acidify the mass and enable the albumen to be 
acted upon by the gastric juice. This may be replaced by other 
acids, such as hydrochloric, or acetic, or malic, for example, in 
some cases. Bile, in the form of inspissated ox-gall, or liquid 



DISEASE AND CURE. 57 

ox-gall in capsules, to supply the place of that which is arrested 
in its passage or in its formation by disease. Pancreatine, 
similar to pepsine. 

4th. Excitants of digestive solvents. — Mineral acids mixed 
with the food increase the flow of bile ; indeed all acid substances 
have the power of exciting alkaline secretions. Thus they are 
useful, not only in jaundice from suppression, but in many cases 
of indigestion where this solvent is too sparingly formed. In 
many cases, too, of flatulence from fermentation of the ingesta, 
mineral acids are beneficial, by causing the pouring out into the 
intestinal canal of bile which arrests putrefaction. Alkalies, on 
the other hand, will also increase the flow of bile. Perhaps it is 
that they supply one of its constituents ; perhaps (as Dr. Harley 
explains it) they stimulate a secretion of gastric juice, according 
to a converse law to that quoted in respect of mineral acids, and 
this gastric juice excites the bile-flow. It is obvious that to ac- 
complish this object, alkalies must be taken on an empty stomach, 
otherwise they are wasted, or rather do harm, by neutralizing 
the acid already mixing with the ingesta. Sugar, peppers, mus- 
tard, spices, and other condiments act in a moderate degree in 
the same way, as may be seen by the effects on the saliva ; but 
their influence is limited. Ease of mind, or cheerful conversa- 
tion, excite the gastric juice ; or, I should rather say, they pre- 
vent the opposite state of mind which retards the secretion. 
Oxygen has a direct effect in exciting the flow of all the digestive 
solvents from the saliva downward. Water increases their 
quantity in the same way that it adds to the solid bulk as well 
as to the liquid bulk of all secretions. 

5th. Artificial replacement of wanting vital functions. — The 
normal animal warmth is a great element in promoting normal 
reconstructive growth. We know how much more readily internal 
wounds heal than external wounds ; how much more quickly, 
when they have been carefully covered up and kept at an even 
temperature, than when they have been laid open to the varying 
influences of the variable air. Disease lowers the power of pro- 
ducing heat in the diseased tissue, or it causes heat to be pro- 
duced in a fitful irregular way. An even artificial heat is there 
5 



58 DISEASE AND CURE. 

fore a strong means of renewing life. Where vitality is deficient 
throughout the whole body, we can economize it by clothing im- 
pervious to atmospheric changes, as woolen, silk, &c, and by 
avoiding linen, as in albuminuria among chronic diseases, and in 
acute rheumatism among acute. Where there is a local deficiency 
of vitality, as in pneumonia, pleurisy, pericarditis, peritonitis, 
ulcerated bowels, &c, none of our curative appliances are so im- 
portant as a continuous poultice. Warm baths supply a large 
quantity of assimilated heat, which lasts for a considerable time, 
and hence, in certain cases, they are felt as a tonic. But they 
will only suit patients who are benefited by, or at least are not 
injured by, the absorption of a great deal of water. 

Electricity supplies the contractile muscular fibers with a 
stimulus to action which is wanting in cases of deficient nerve- 
force. Hence it keeps up the habit of motion in paralytic limbs, 
prevents their getting atrophied, and sustains them in possible 
activity till such time as the injured nerve-force recovers itself. 
Artificial motion and rubbing act much in the same way. Me- 
chanical aids to sight, sound, hearing, and movements, rightly 
employed, may come under the same category. 

6th. A temporary revival of deficient functions. — For example, 
the deepening of sluggish breathing by ammonia, valerian, ethers, 
and essential oils. This stimulation, though it may be only tem- 
porary upon the organ directly acted upon, is therefore followed 
by a reactionary collapse ; yet indirectly it contributes to life by 
the influence of the organ's functions upon other parts. Thus 
the deepening of the breathing, instanced just now, aerates the 
blood and strengthens the circulation, and so makes to the capi- 
tal of life an addition which lasts long after the passing stimulus 
has lapsed into a corresponding degree of deficiency. Perhaps 
the permanent benefit of ivarm bathing, often so much greater 
han can be accounted for by the short increase of warmth, may 
be explained in the same way. Alcohol often acts beneficially 
in full doses at long intervals, in cases where its continued in- 
fluence in smaller doses would be hurtful, probably on this same 
principle. But as a general rule, those stimulants are to be pre- 
ferred for the purpose whose effect is more transient. 



DISEASE AND CUKE. 59 

7th. Increasers of absorption are purely constructive medi- 
cines, provided that they are not increasers of destructive meta- 
morphosis at the same time. Vegetable bitters brace up and 
harden the mucous membranes, as may be easily tried by their 
effect on the mouth. Hence exosmosis is lessened, and endosmosis 
increased. Thus digestion is made more rapid and effectual, 
more nutriment is taken up and quicker. Even in a healthy 
person the remains of the last meal are sooner disposed of, and 
the appetite for the next sharpened by a bitter. This is the pure 
action of a vegetable bitter ; but a good many of the plants we 
use as such contain various matters which otherwise unfit them 
for our purposes in certain cases. Perhaps none exercise so few 
of these noxious influences and are more generally applicable 
than the products of the inimitable cinchona. Astringents also 
may reasonably have some of their beneficial influence on the 
digestive canal explained by their restraining the formation of 
mucus. When mucus is in excess, it doubtless interferes much 
with the taking up of nutriment by mucous membranes, and the 
checking its growth is an indirectly constructive act. Many of 
the vegetable bitter drugs contain tannin or other astringent 
constituents, and are thus peculiarly suited to the leucophleg- 
matic (or mucogenous) diathesis. These drugs are suitable not 
only for the digestive canal, but to other internal tegumentary 
membranes. Thus the renewal of life in the uterus and ovaria 
is very much aided by checking leucorrhcea with astringent injec- 
tions. The absent catamenia will often reappear while the 
weakening discharge is being thus arrested ; and stagnant ulcers 
will form fresh healthy tissue, wounds will close, and abscesses 
heal after, nay, during the application to them of astringents. 
Sulphate of copper and nitrate of silver are most active in this 
way ; but, as you know well from your experience as dressers, 
heed must be taken lest when destroying the mucus and pus- 
formation you also destroy the life of the adjoining tissues whose 
preservation is your care. Sulphate of copper is a most j^owerful 
internal medicine, as a reviver of health in ulcerated parts of the 
intestinal canal, and it also seems to act as a tonic generally 
to the digestive tract. Nitrate of silver would probably be equally 



60 DISEASE AND CURE. 

useful, but unhappily it is too soon converted into the inert chlo- 
ride by the salt of the secretions. 

8th. Excitants of the involuntary muscles which subserve 
absorption are also constructives. Thus strychnia and aloes 
increase the appetite by hastening the passage of the alimentary 
mass, and this joined to their bitterness makes them tonics. But 
they both are better when aided by other tonics. Succussion 
stimulates these muscles, and so very gentle exercise promotes 
digestion, but violent muscular exertions arrest it, because they 
engage the nervous energy elsewhere. 

There are certain drugs which, in a manner as yet quite un- 
explained by physiology, appear to alter toward health particular 
tissues. They are not constituents of the body, nor do they seem 
suited to take the place of constituents of the body, nor do they 
cause any evacuation of retained effeta, nor do they apparently 
act on any of the healthy organs. Iodine and bromine, for ex- 
ample, have this effect on the white fibrous tissues, and as they 
originate renewal, I can hardly help classing them among con- 
structives. 

With Destructives our forefathers have left us well ac- 
quainted. Time out of mind the world has had long lists of 
drugs, classified according to the organs through whose gates 
they disgorge the products of metamorphosis. " Sudorifics," 
"purgatives," "diuretics," "expectorants," &c, are familiar to 
sboth doctors and the unlearned ; while others, as mercury for 
example, are known as general " liquefacients," promoting de- 
structive metamorphosis universally, and a consequent increase 
of solid evacuation from all quarters. And other expedients 
again, such as bleeding, are a direct mechanical abstraction of a 
part of the living body. 

The uses of Destructives are the following : 

1st. To remove from the system effete matters which are toxi- 
cally noxious to healthy life. — Nothing does this so universally as 
water. The biliverdin which we see staining the skin in jaundice, 
and which indicates also the presence of the more injurious 
biliary acids, may be removed by mercurials, by podophyllin, by 



DISEASE AND CURE. 61 

soda, and, according to Dr. Harley, by benzoic acid, provided 
always care be taken that the passage for their exit is free, that 
the bile-ducts are not obstructed. So also uric acid may be 
eliminated from the blood by niter and by some other neutral 
salts, when the kidneys are healthy and neither degenerated nor 
congested. In applying these remedies it is necessary to see 
clearly what is the effete matter we wish to get rid of, and to use 
the appropriate drug. No laborers in the present field of materia 
medica deserve so well of the world as those who inquire into the 
real intimate working of medicines. Our chemists' shops are 
quite full enough, and it adds much more to true useful knowledge 
to make a single step toward explaining the action of one estab- 
lished remedy, than to add a hundred even active articles to the 
pharmacopoeia. One would be glad to know in the case of each 
eliminating drug which of the effete constituents it most readily 
acts upon. Thus much milder drugs might often be employed, 
which would go straight to the point, instead of having some 
violent but perhaps unnecessary action joined to them. Do not 
let us be satisfied with the nomenclature of " purgatives," "diu- 
retics," "sudorifics," if it is possible to discover what it is they 
purge out, what constituent is specially removed through the 
kidneys and what through the skin by the augmented secretion. 
2d. To remove mechanical impediments to normal excretion. — 
The proviso which I made just now in the case of the liver and 
kidneys, namely, that there should be nothing in their structural 
state which can impede the flow of bile or the urinary constitu- 
ents, reminds us of another use for destructives. For example, 
leeches on the right hypochondrium will often restore a flow of 
bile, in diminishing a congestion of the hepatic tissue by which 
its formation may be stayed. Cupping the loins will act as a 
diuretic by relieving congestion of the kidneys after scarlatina or 
other cause. Leeches to the anus, or artificial hsemorrhois, will 
empty the stagnant portal circulation, resuscitate its activity, 
and by this means enable medicines to be absorbed and food to 
be digested. General bleeding will at a great expense to the 
system, and not perhaps more readily, effect all these objects at 
once. The advantage of venesection to our forefathers was that 



62 DISEASE AND CURE. 

it did not require any accuracy of diagnosis of the organ to be 
attacked, but made a general assault on all together. 

3d. The removal of impediment to absorption is another good 
reason for the administration of sundry destructive medicines. 
This is often merely a question of mechanics, and if we could 
apply mechanical means to the required locality, they often 
would do better. Such for example is the removal from the 
stomach and intestinal canal of mucus, whether peopled with 
parasitic worms or not. Mucus is in itself peculiarly insoluble, 
and therefore indigestible, and it also firmly resists diosmose : 
thus its presence stands in the way of the absorption of nutri- 
ment by the digestive membranes. It is not easy to rid the 
patient of these incumbrances without abnormally augmenting 
destructive excretion, but if it can be done we should be glad to 
do it. 

4th. The removal of systemic poisons which are the cause of 
disease by destructives seems shown to be possible by the effect 
of mercury on the syphilitic virus. The body is endowed with 
power to gradually eliminate this virus, and after a course of 
diseased states of long, perhaps years-long duration, to return 
again to health. Indeed if it had not this power, remedies would 
be useless ; for drugs, though they can arouse sluggish capabilities, 
can bestow none not originally inherent in the nature. The natu- 
ral elimination, tedious always and perhaps sometimes otherwise 
impossible, is, according to Mr. Lee and other experienced syphi- 
lographers of late years, much quickened by mercury. Mercury 
does not, like sarsaparilla, bark, iodide of potassium, and other 
constructives, benefit by curing the diseases caused by the virus ; 
it aids the system to destroy the virus itself. That it should do 
so is not surprising when we see its wonderful destructive action 
on animal tissues ; how they become softened and blanched and 
dwindled in decay when the system is saturated with the drug. 

Were there any other chronic diseases so indubitably kept up 
by the obstinate adhesion in the system of a morbid poison, it 
might be worth while to destroy the poison in the same way. It 
might be worth while to submit to having the healthy parts of 
the body scotched, for the sake of prematurely killing its baleful 



DISEASE AND CURE. 63 

guest ; but I do not think we can find another instance among 
maladies common enough for us to be well acquainted with their 
pathology. 

In acute fevers dependent on organic poison the system casts 
it forth so quickly that sometimes danger is borne of its very 
haste and effervescence. We should be at no pains to hurry the 
process, did we possess the capability of doing so. Under the 
same restrictions as morbid poisons comes the removal of inde- 
pendent parasites, such as lice, itch acari, the fungi of favus and 
pityriasis versicolor, of dead or incurable parts of the body 
which react upon and become the causes of diseases, and of 
foreign matters generally. We must balance the injury we may 
be obliged to inflict in removing them against the good done by 
such removal. 

A free review of the rational reasons for using destructive 
treatments in the cases I have given as examples, will confirm 
the universal rule that they are never to be employed for their 
own sake, but only to either make room for, or to give play to, 
constructive growth. 

Arresters of constructive life, as such, can scarcely come 
under the denomination of medicines ; physicians never wish to 
stop growth in human patients. As poisons we do use them on 
animals for certain purposes of our own: alcohol is given to 
puppies to keep them small dogs ; and it is stated that dwarf- 
like jockeys have been produced by the same treatment. We 
have thus a warning of what the effect of the agent is. 

The same article of diet, however, appears in another light as 
an arrester of destruction. We not seldom wish to stay the pro- 
cess of vital decay in our patients, and are provided with a means 
of doing so in alcohol. In a lecture published some time ago* I 

* Lecture XLVII of this volume. I would take this opportunity of saying that 
the lectures are not placed in the order in which they were delivered. Clinical 
instruction is. or should be, given as the cases occur; so that the student should 
come fresh from the bedside observation of the patient to the deductions made 
therefrom. Introductories, however, at the beginning of each session, afford a 
legitimate opportunity for a systematic statement of principles, for going back to 
the abstract truths which are the result of previous practice and experience. To 



64 DISEASE AND CUEE. 

explained the reasons for thus viewing alcohol, and went into 
details of the circumstances which should guide and govern its 
administration ; so I will not repeat them now. I there classed 
it as an anaesthetic, whose primary action is on the nervous sys- 
tem, and attributed to that action its effect in staying destructive 
metamorphosis. 

Our other more generally acknowledged anaesthetics have a 
similar action ; they prevent the wearing out of the body by the 
painful and destructive functioning of the nervous system during 
disease. 

Why is the functioning of the nervous system during disease 
painful and destructive ? It seems to me that M. Chossat's ex- 
periments throw some light on this obscure subject. The nervous 
system is the "ultimum moriens" — the member of the body the 
least affected by vital decay, that upon which starvation, de- 
ficiency of life, disease, have least decomposing influence. It 
remains therefore energetic, sensitive, and motive, while the 
others become deadened and sluggish. Thus the due balance of 
the functions is overthrown. By a restriction placed upon the 
normal but inconvenient force of the nervous system we get a 
state more like to health, by reason of its nearer approach to 
balance, and guard the tissues against the disorganizing tendency 
of its abnormal disturbance. 

The same aim of restoring the balance may be effected by 
raising the depressed vitality of the non-nervous deficient func- 
tions. And where this can be done, of course it is the best 
treatment. Where means of accomplishing such a desirable ob- 
ject are wanting, anaesthetics are the next best resource. Just 
as in machinery when a wheel has got worn and inefficient, it is 
best to put in a new one, if possible ; but where we cannot, we 
slacken the steam power — quod opihus deest, arte sarcimus. 

Is pain the expression of the want of balance I have spoken of, 
or is it only a co-ordinate phenomenon ? Certain it is that pure 

the reader it is convenient that these should come together at the onset ; and the 
sequence of time being thus disturbed, I have preferred to set the rest in a sort 
of natural order, putting together those which seemed to have most bearing on 
one another, rather than to arrange them chronologically. 



DISEASE AND CURE. 65 

pain, such as neuralgia, is relieved either on raising the vital 
functions with food, tonics, &c, or on blunting the nerves with 
anaesthetics. 

Remark now that destructives and arresters are not in any 
case final treatment ; the end is in every instance reconstruction 
or renewal — an aim which must be kept in view in all the physi- 
cian does or counsels. 

These principles of therapeutics I make it the business of my 
clinical lectures to enforce and illustrate by the examples of 
disease which you are at the moment seeing under your eyes. 
But do not suppose these examples to be picked examples — cases 
selected to prove my points : no — each one of my patients in the 
wards teaches the same lessons to all, at least to all those who 
are willing to be taught by nature rather than by books. Let 
me entreat of you not to neglect the opportunity which is afforded 
by our liberal public charities and the independence of your pupi- 
lage to learn truth, and jthen you will not fail in after-years to 
practice truth. 



LECTURE III. 

THE FORMATION OF MUCUS AND PUS. 

Office of mucous membranes — The identity of mucous globules 
and nascent epithelium — Self-supported growth of mucous 
globules — Similar to organic growth of a parasite — Is this 
form of life an excess or a deficiency of normal life f 

(First Lumleian Lecture at the College of Physicians, 
Lent, 1863.) 

The subject which I have chosen for these Lumleian Lectures 
is one which must be interesting to physicians above all other 
observers of nature. A physiological Fellow of our College was 
in the habit of reckoning his patients as so many "mucous mem- 
branes." On his retirement from active practice he said, " I have 
taken my last fee from my last mucous membrane." I do 
not think his term was an exaggeration, for in very few indeed 
of the cases ministered to by us has not either the cause of the 
death acted on the body through these integumentary coverings, 
or manifested its action by a perversion of their functions. A 
great majority of our drugs are intended to act on mucous mem- 
brane, and all are introduced into the body through it. We can- 
not therefore but be grateful to those who have endeavored to 
add to our knowledge of its nature and habits. 

The term by which it is conventionally designated is apt to 
lead the most thoughtful of us into a fallacy. Active members 
of society are named after the work which is their most important 
occupation. The industry of the lawyer is the administration of 



THE FORMATION OF MUCUS AND PUS. 67 

the "law;" the doctor is most efficient when he is most "learned;" 
the duty of bishops and overseers is eiriaKoireiv "to oversee" each 
their several departments. But the office of mucous membrane 
is not to secrete mucus. It is most active when it is not doing so, 
and its activity is decreased just in proportion to the copiousness 
of the mucus. Typical health certainly consists in its absence ; 
many robust people pass weeks without expectorating; many 
find their handkerchiefs clean and unrumpled after being days 
in their pockets, in spite of all the artificial and accidental irri- 
tants to which the Schneiderian membrane is subject ; and the 
urinary and intestinal canals contribute only an infinitesimal 
quantity, which may fairly be attributed to a temporary departure 
from health of some fraction of their large area. 

The business of mucous membrane is to offer a passage for 
oxygen, water, fat, albumen, and other nutrimentary substances, 
and to defend the less easily renewed tissues beneath it from the 
deleterious action of external agents. These functions it best 
fulfills when it is bedewed with a moderate watery exhalation, 
and not with mucus. 

This exhalation is transparent and watery, and possesses 
nothing of that stringy adherent character by which we ordi- 
narily recognize the substance known as mucus. It carries out 
with it the epithelium scales shed or moulted from the surface ; 
and these scales are consequently found in the excretions ; but 
it is itself absorbed again as quickly as it is exhaled, and does 
not contribute to the substance of any of the ejecta of the body. 
The typical healthy condition of a mucous membrane may be 
considered to be a constant dampness without visible fluid, and 
a moderate and gradual shedding of epithelium. 

Shed epithelia are found also in mucus, but not as a peculiar 
characteristic, nor modifying its physical properties. Its most 
obvious characteristic is the presence of transparent bodies, ap- 
parently of a gelatinous consistence, of a more or less rounded 
or oval form, and with one or more nuclei, seemingly of a less 
transparent consistence, in their interior. But its physical 
properties of consistence and adhesiveness, which so peculiarly 
distinguish it from all other transparent fluids, seem to be de- 



68 THE FORMATION OF MUCUS AND PUS. 

rived from the medium in which these globules are placed. This 
origin may be inferred because similar globules, quite undis- 
tinguishable in appearance and behavior, constitute also the bulk 
of pus, a fluid of quite distinct attributes and properties. 

There are probably no observations more suggestive and 
luciferous to rational medicine than those contained in the paper 
of Henle published about a quarter of a century ago in Hufe- 
land's Journal. It is an excellent example of physiological 
reasoning, and later observation seems to set the matters of 
which it deals beyond reasonable doubt. 

Professor Henle's argument aims, successfully I think, at 
tracing the globules which are seen in mucus under the micro- 
scope to that substance which in the normal state of typical per- 
fection would form epithelium. They appear to be young eithelium 
arrested in its growth, and prematurely moulted off from the 
body. The condition which produces them is an arrest of de- 
velopment. 

To feel the full force of the experiments and observations 
which confirm this view, it is necessary to see the connecting 
links of resemblance which run through the course of the integu- 
mentary membranes. We must pass over for the nonce the 
differences which fit for their various uses the external skin, the 
covering of the tongue and mouth, the secreting lining of the 
stomach, the absorbing lining of the intestines, the defensive 
coats of the bladder, urethra, rectum, &c. We must look upon 
them as one whole. Just as the skin clothes the muscular frame- 
work of the body, moulded on the form of the skeleton, so the 
mucous membrane lines the internal canals, pits, and galleries, 
following their intricate windings throughout. And for exactly 
the same purpose — namely, to be a defensive medium of com- 
munication between the individual being and the outer world, 
between the microcosm and the megalocosm, in all their chemical 
and mechanical relations to one another. 

For the fulfillment of this common duty they have a common 
structure. Strip off a piece of epidermis, and you find that its 
outermost layer consists of flat polygonal scales pressed close 
together and united both by the edges and surfaces so as to form 



THE FORMATION OF MUCUS AND PUS. 69 

a continuous leathery tissue. They are welded into one fabric 
like the exposed part of an old macadamized road. But just as, 
when you pick up the surface of this road, you expose a deeper 
layer of stones loose and separate, so beneath the scarf skin you 
find what Malpighi, with philosophical prescience, called the rete 
mueosum. This consists, like the scarf skin, of separate corpuscles, 
which, like the stones of the macadamized road, become looser 
in structure, less adherent, and less similar to the upper layers 
as you go deeper. The superior corpuscles are indeed flattened, 
and exhibit a flattened nucleus inclosed in a clear cell as an 
epidermoid scale. But as you get nearer the cutis the nuclei are 
rounder and rounder, and the transparent area of the cell is less 
and less visible ; until at last, on the cutis, the corpuscles are 
seen to consist of only granular masses. These granular masses 
are identical with those seen in mucus. 

Just in the same way the mucous membranes are clothed with 
epithelium, loosely scaly in some parts, welded together like a 
macadamized pavement in another, columnar in another. And 
when this is stripped off or injured, there are brought into view 
floating granular masses of various sizes, which constitute what 
are familiarly known as "mucous globules." They are exactly 
identical with the inner strata of the epidermis, the rete mueosum 
of Malpighi. 

What are these globules ? Are they something special, be- 
longing to special tissues, and appearing only under special cir- 
cumstances ? Or are they a form of organic matter common to 
other parts also ? Are we to apply here the Baconian myth of 
Proteus, and look for their natura naturans as exhibited else- 
where in various shapes? I think it is philosophical to do so. 

The appearance they have is that of all matter when it first 
puts on life. The telescope and the microscope equally reveal 
to us these nebulae as the earliest indication of vitality, drawing 
the surrounding chaos toward a central point, then exhibiting 
that central point as a kernel or nucleus. And then this kernel 
becomes the parent of new centers, individual and separate, and 
these again starting-places of new action. The dawn of vitality 
is exhibited in the coalescence of molecules of organic matter so 



70 THE FORMATION OF MUCUS AND PUS. 

as to form nuclei, which, under favorable circumstances, develop 
either separate cells or tissues. 

Up to this point each focus of life seems to be a separate in- 
dividual. It takes in nourishment by its innate power from 
without ; it increases in size and alters in shape. And this 
alteration in shape seems principally to take place from within. 
It is not merely an aggregation outside of new molecules, but a 
plastic change of internal appearance. Nay more, it possesses 
the faculty of giving birth to an individual, and so to a succes- 
sion of individuals, like itself. No better evidence of automatic 
existence can probably be given. 

These phenomena can be seen without much difficulty in the 
globules of mucus. That which answers best is what we often 
expectorate in little semi-transparent gelatinous lumps from the 
bronchi in the morning after exposure to night air. This must 
not be mixed with water, or be allowed to cool, but kept at the 
temperature of the body, and put immediately under a lens of as 
high a power as you can command. Dr. Beale showed me the 
phenomena first under a 24th, but I have seen them very well 
under an 8th inch in an old-fashioned Powel's microscope. Keep 
your eye fixed on one nuclear mass, and you will often see a 
gradual change in its appearance. First a clearer nucleus ap- 
pears in it ; then, as you gaze, two, three, or more smaller nuclei. 
Then the fine granular specks in its sides coalesce into a nucleus. 
Then you see that it has a bulge in its side, and that a nucleus 
forms a bud, and then has a constricted neck or stalk. And then, 
perhaps, if you are lucky enough to get the mucus in motion 
without losing sight of your object, the bud may float off as a 

separate globule. Or the whole 
globule may divide into two, each 
with a separate nucleus, as I have 
tried to represent in this drawing 
from life of five globules in this 
state of transition — 
A temperature below that of the body seems to check this de- 
velopment, but you may often keep it on by means of a spirit- 
lamp. The globules in which I have seen it take place are those 




THE FORMATION OF MUCUS AND PUS. 71 

from the trachea, from the os uteri, and from warm freshly- 
passed urine in cases of inflamed bladder. 

* When the fluid has got dried up by the heat thus constantly 
applied, you may in some degree restore its activity by moisten- 
ing it with a viscid animal fluid, such as saliva. The greater part, 
indeed, is broken up into molecules, and these show no disposition 
to unite into globules, but among them will remain some globules 
unbroken, and these will again form new nuclei, and bud as they 
did at first. 

Is this organic growth? Or is it the aggregation into visible 
masses of particles already existing, like that which Mr. Rainey 
has described as taking place in mineral matters ? Is it a mere 
coalescence, or something more ? I must say that to my mind 
the production of an individual like itself, capable again of 
reproducing another individual still resembling the grandmother 
globule, is identical with organization. And I think, too, that 
the multiplication of the nuclei inside is quite unlike any sort of 
coalescence, which would add matter to the outside, like an 
urinary calculus or an avalanche. 

It seems to me that each of the globules contains a center of 
life, into which the pabulum passes from the outside, nourishing 
them and giving them means to increase in number. This would 
account for the enormously rapid collection of mucus filled with 
globules on inflamed membranes, even on membranes which in 
the healthy state shed very little epithelium, or have but one 
layer of it, as in the bronchi, and therefore cannot be supposed 
naturally to form much young epithelium. The first parent 
globules may be aborted young epithelium cells, and these may 
be the ancestors of others which form the bulk of the mucus, 
begetting them with the extreme rapidity characteristic of gen- 
eration in low organic life. 

If this be true, mucus may be viewed as a parasite, receiving 
from the body its nutriment indeed, but not in its form nor its 
claim to vitality. 

Doubtless the growth of mucus is most rapid where there is 
normally a thick layer of epithelium, and where a large growth 
of young epithelium is constantly being formed to replace the 



72 THE FORMATION OF MUCUS AND PUS. 

rapid moulting. But still it is much quicker on localities with 
a thin layer than could be accounted for by each globule being 
an aborted scale; there could not be enough aborted scales to 
furnish so much mucus so full of globules. I believe, therefore, 
that it grows on the surface by their budding and splitting in 
continuous succession. 

If you compare pus which has been some time accumulating 
on the surface of a mucous membrane with that which is being 
freshly formed, you will remark a decided difference in the 
globules they contain. Take some accessible mucous surface — 
the eye, or the vagina, for example — thickly covered with opaque 
secretion, and you will find the globules nearly all of a size, 
even and spherical. Then wash it clean with cold water, and 
examine the first-formed secretion : the globules are of all sizes 
and of irregular shapes, oval, bulging, budding, with or without 
nuclei. This seems to indicate a general change of form by 
time — a certain completion of creation in that which has been 
longest formed. 

When we see, as I have described, the globules of mucus 
budding, dividing, and subdividing in active haste — new foci of 
independent vitality generated and multiplying even when sepa- 
rated from the body — it might appear that a local increase of 
life was being exhibited. Certainly a greater bulk of living 
substance is formed by a membrane secreting mucus or pus, 
than is the case in the healthy state; for the secretion out- 
weighs by a hundredfold the daily quantity of epithelium which 
its original material was destined to make. But what sort of 
degree of life is exhibited by this secretion? Is rapidity of 
multiplication to be looked upon as evidence for or against force 
of vitality? Against, I think. The lower we go in the scale 
of creation, the more quickly and the more copiously do the 
living forms representing the various classes reproduce their 
kind. The less functions and force and intensity of existence 
they have, the more prominent becomes reproduction as the 
main object of their being created. This seems to be the uni- 
versal rule, to be traced all through living beings till we get 
down to the Amoeba and the mould, in which no trace of a 



THE FORMATION OF MUCUS AND PUS. 73 

function can be detected beyond the multiplication of their 
simple substance. 

Here, indeed, it becomes difficult to draw the line between 
organic and inorganic. Instead of being in contrast and in con- 
flict with the physical force of inanimate nature, vitality seems 
to obey laws which closely resemble them. The main point of 
distinction seems to be the growing from a center outward of 
organic, and the aggregation toward the center of inorganic, 
individuals. 

When organic matter destined to form part of an animal has 
attained the end of so becoming a member of a consistent whole, 
it ceases to multiply itself. Cells do not normally go on split- 
ting up and producing cells similar to themselves in situ. The 
highest development of their vitality is ceasing to exist as grow- 
ing matter. A fully-formed epithelium scale does not produce 
another scale, nor the nucleus of a muscular fiber another nu- 
cleus. The retention of reproductive force is an expression of 
the lower and an exclusion from the higher functions of life. 

In the mucous globule, then, we find organic matter, whose 
destination was the formation of epithelium, arrested in its 
development when it has attained only the lowest degree of 
life — that lowest degree of life being the function of repro- 
duction. 



LECTURE IV. 
THE FORMATION OF MUCUS AND PUS. 

Mucous globules not cells, but nuclear matter — The representative 
of the cell is the medium in which they float — It is therefore 
not likely to retrogade into globules — Formation of pus from 
mucus — How does pus appear on the surface? — Observa- 
tions of several observers — Passage of globules through 
epithelium — Pus-globules not descendants of epithelial cells, 
but parasitic formations inside them — Epithelium semifluid 
— Breach of epithelium in some cases — Growth of pus. 

[Second Lumleian Lecture at the College of Physicians, 
Lent, 1863.) 

I described in my last lecture the mucous globule forming 
nuclei in its center, and these nuclei splitting up into two or 
more, subdividing and separating the whole globule into several. 
From this it has been inferred that it is in this way that the 
globules grow — that they are, in fact, cells which multiply by 
subdivision. But I described also the formation of buds at the 
side of the globules. These buds commence by the granules 
of which the mass of the globule consists becoming gradually 
more visible and distinct, and forming centers of growth distinct 
and separated by a conspicuous interval from the central nuclei. 
They are not derivatives from the central nuclei, but new start- 
ing-points of growth. This is important, because it takes the 
globules out of the category of cells. In a fully-formed cell 



THE FORMATION OF MUCUS AND PUS. 75 

it is only the nucleus, and not the transparent area of formed 
matter, which grows; whereas here the whole substance grows 
and originates growth. The globules are, in fact, nuclei. Or 
we may more properly call them "nuclear matter;" for a nu- 
cleus must be a nucleus of something, whereas these are nuclei 
of nothing. Nuclear matter is that which is fitted to be the 
nucleus of something, unless arrested in its development — in 
other words, organic living matter in a condition to grow and 
multiply. A confirmation of this occurs in a drawing by Dr. 
Beale. "When tissues are steeped in a weak solution of carmine, 
the only parts which receive a permanent stain are the nuclei, or 
young growing matter in them. Now, of the mucous globules 
the whole substance receives a permanent stain, as is shown in 
the drawing here exhibited. It appears, therefore, to be wholly 
formed of nuclear or growing matter. 

It may be remarked that the mucin, or transparent fluid 
medium in which the globules float, does not receive so marked 
and so permanent a stain from the carmine; and this appears 
a very fair argument for considering it as the formed substance 
of which the globules are the nuclei — a sort of common trans- 
parent area, a common cell-wall to numerous nuclei ; just as 
coral is the common skeleton to millions of coral insects. Each 
perfect epithelial scale, each nucleus, has its own formed sub- 
stance constituting its own cell-wall; in the lower grade of life 
represented by mucus there is a less perfect common formed 
substance, constituting a common cell-wall. 

Now, if the mucin, or transparent medium in which the 
globules and granules float, stand in the place of fully-formed 
organic substance or cell, it will not retrograde into the condi- 
tion of growing substance. Such a retrogression does not happen 
in cells. In an epithelial scale, for instance, the transparent 
area does not become nuclear matter. But it transmits the nu- 
triment to the nucleus inward through its substance without 
being destroyed. On this supposition, the formation of mucin 
will be the highest development of the life of the globule, for it 
answers to the formation of tissue from nuclear matter. And 
in that case we should expect to find that the nearer its normal 



76 THE FORMATION OF MUCUS AND PUS. 

condition the morbid secretion can be collected, the more of this 
higher state of life it would exhibit, and that the further from 
its normal condition it is, the less there would be of the formed 
matter. Such is the fact. The fluid which first forms on an 
inflamed surface contains few globules and much stringy trans- 
parent medium. Its nuclear matter has so far departed from 
life that it cannot form separate cells, but only an imperfect 
common area. But as the inflammation goes on, this power is 
still more and more lost; the nuclear matter cannot form the 
mucin, it can only multiply; and hence the stringiness of the 
mucus disappears, and it becomes what we know by the name of 
"pus." As far as the morbid matter itself is concerned, pus 
indicates in it a further deficiency of vitality than mucus — a de- 
ficiency of vitality shown first in its internal self-multiplication, 
and secondly in its non-production of mucin. 

The question naturally arises as to how these products of 
arrested vitality make their way to the surface of the mucous 
membrane where we find them. The pabulum whence they are 
developed lies on the inner side of the epithelium, whereas we 
find them quite uncovered. The first explanation that occurs 
would be that the epithelium is destroyed, and that they are in 
the first place the debris of the dissolution, united to that which 
would normally go to form it. This would, in fact, be a modifi- 
cation of the old idea, that pyogenesis was a kind of ulceration, 
and involved a certain solution of continuity in a tissue. In- 
deed, it would amplify the idea, for it would extend its applica- 
tion to mucus as well. To this idea Professor Virchow seems to 
incline in the edition of his "Cellular Pathology" published in 
1858 (p. 395), where he represents the formation indeed of the 
mucus and pus-globules to take place in the lower layers of the 
epithelium, but to be mixed with and to have their bulk added 
to by the outer layers which they push off. 

Since then, however, several observers have found that the 
most intense catarrhal condition of mucous membranes may exist 
without any loss of the superficial epithelium. Even in that most 
destructive state commonly known as diphtheritic inflammation, 
where fibrin is thrown out with the pus, the epithelium may be 



THE FORMATION OF MUCUS AND PUS. 77 

perfect. Dr. Sanderson has kindly lent me some notes he made 
of the autopsy of a child who died at St. Mary's Hospital of 
diphtheritic angina, in whose larynx this fact was very clearly 
seen. The whole interior of the organ was lined with a firm, 
closely adherent false membrane. When that was detached, 
portions of flabby concretion still remained, which could be 
washed off with a stream of water. " On examining the sur- 
face," says Dr. Sanderson, "after much washing, it was found 
to be entire. It exhibits to the naked eye, indeed, marked in- 
equalities of appearance, as if eroded; but these must be de- 
pendent on the adhesion of minute particles of concretion; for, 
on making snips of the surface with sharp scissors at those parts 
where the eroded appearance was most obvious, viz., on the 
upper surface of the epiglottis, the epithelium was found to be 
entire. The only exception was at the upper margin of the 
ventricles, where the epithelium was adherent only here and 
there ; but there was no trace of thickening or alteration of the 
basis-membrane, which exhibited its normal appearance."* 

Forsterf has also carefully examined, by both horizontal and 
perpendicular section, the epithelium of mucous membranes in 
a state of purulent catarrh, and has found in it either no change 
or very unimportant change from the normal state. 

The globules, then, or the material of the globules, must some- 
how be passed through the epithelium. Dr. Buhl, of Munich, 
has lately detected it in transitu, and drawn figures of it on the 
road. The case on which his observations were made was one 
particularly well suited for the purpose. The patient had died 
of pyemic inflammation of the portal vein and of the bile-ducts 
of the liver. Now, the epithelium of the bile- ducts presents a 
very marked character; its cylindrical bodies exhibit an unmis- 
takable shape. So obvious is this shape that it can be detected 
even when considerably distorted ; and therefore he was able to 
trace the epithelium scale, modified by what he rationally enough 
concludes to be the presence in it of pus-globules. This is clearly 

* Private Notes of Dr. Sanderson. 

j Communication from the Wiirzburg Institute of Physiology and Anatomy. 
Wiirzburger Med. Zeitschrift,'' bd. i, part 2. 



78 



THE FORMATION OF MUCUS AND PUS. 



exhibited in his sketches of the various forms or stages of altered 
epithelium as he saw it floating loose in the fluid pus or massed 
into clots. First, he shows the normal epithelium cylinder, as 
a medium of comparison, and of these there were great quan- 
tities. Then come a number of bodies which we can recognize, 
when they are here placed in a row, as perversions of the cyl- 
inder, gradually increasing in rotundity and receding in likeness; 
but which in their extreme of dissimilarity would not be seen to 
have any connection with it, except by a previous knowledge of 
the fact. 




{After Buhl.) 

The majority of the enlarged cells were filled with oil-granules. 
Others, in which the fat was accumulated to a smaller amount, 
contained from two to ten rounded bodies exactly like the free 
pus-globules surrounding them — so like, that hardly any doubt 
could be entertained that they were cells pregnant with pus- 
globules. As a rule, the groups of pus-globules lay close to the 
thick end of the cylinder; but often between the thick end and 
the groups of pus-globules there was to be seen a degree of con- 
striction, making the cell bottle-shaped. Sometimes the tail of 
the cell was obliterated or torn off, when it was almost globular, 
but even then capable of recognition. 

In cells where there were only two or three globules the 
nucleus remained distinctly visible and perfect. In others the 
granular globules seemed to be dividing and splitting up into 
four or six, the original nucleus of the cylinder still remaining 



THE FORMATION OF MUCUS AND PUS. 79 

visible. So that pus-globules evidently do not of necessity take 
their rise in the degeneration of nuclei of existing tissue. 

In other examples, again, the cell-contents seem entirely to 
have degenerated into fatty molecules, whether from the growth 
of the globules just described or from other causes, and in them 
the nucleus had degenerated along with the rest of the cell. 

I have noticed in the epithelial scales from the vagina, in 
cases of purulent discharge, a somewhat similar repletion with 
granular matter without alteration of the nucleus. And mixed 
with them there were also large round granular corpuscles, which 
had the appearance of containing pus-globules, and which might 
have been degenerated epithelial scales. But scaly epithelium 
has not such a definitely marked form as the cylindrical variety, 
and it is difficult to identify it in a state of transmutation. 

Remak* has also found in the pus from inflamed bladder large 
cells which he thought he identified as the epithelium from the 
fundus vesicae. These contained from six to fifteen globules, 
entirely filling up the interior, and in every respect like mucus- 
corpuscles. But he does not trace a series of transitional forms.. 

It will be seen by these observations that the pus-corpuscles 
are not so much descendants of the epithelial cells as what may 
be called parasitic formations within them. They are parasites 
inside the epithelial cells, capable of increase by propagation 
within the tissue, just as on the surface the mucous globules were 
shown as parasites capable of increase by propagation without 
the tissue. And they grow quite independent of the true nucleus 
of the cell, and are not derived from it. Thus the nuclear 
material may pass through the substance of the epithelial coat of 
mucous membrane without destroying it, and not only be itself 
unaltered, but may increase in quantity during the progress. 
This is one way in which the pus-material may reach the sur- 
face, and explains those cases in which the epithelium is quite 
uninjured. 

We find these fluid or semifluid properties exhibited by epithe- 
lial cells in their daily duty of absorption. Fat, from its highly 
refractive powers, can easily be traced, though a fluid, by the 

* Virchow's "Archiv," bd. xx, p. 198.. 



80 



THE FORMATION OF MUCUS AND PUS. 



microscope ; and fat in globules can be seen passing through the 
substance of the epithelial cells of the intestines during their 
active state. This is well shown in some recent drawings, made 
bj Balogh,* of intestinal epithelium during the ingestion of fat ; 
the whole thickness, not a central tube, but the whole thickness 
of the cell, is seen permeated by it, and allowing it free passage. 
The physiological passage of fat-globules inward may reconcile 
us to the idea of the pathological passage of pus outward. 

But Professor Henle well says : " If they are sometimes formed 
in the interior of a cell saturated with their material, this fact 
does not exclude the possibility that just in the same way they 
may sometimes be developed from the same plasma beneath the 
cells." In such case they would be projected on to the surface 
between the separated epithelium cells. 

This other mode of growth and attaining the surface is strik- 
ingly shown in a drawing by Dr. Edward Rindfleisch, of Breslau,f 
which exhibits in section the nictitating membrane of a frog 
affected with a partial catarrh of the eyes. Fig. 3 is the normal 
state, where the membrana propria (as Professor Henle calls it) 
is seen as a moderately transparent layer, with its delicate 

Fig. 3. Fig. 4. 

® 





[After Rindfleisch.) 

areolar-tissue-corpuscles, and the epithelium as two parallel rows 
of equal-sized cells. In Fig. 4 the pathological condition is re- 
presented : the pavement of epithelium is thrown up and sepa- 
rated by nucleated pus or mucus-globules, which are seen to 
proceed from the membrane beneath. And the substance of this 
membrane appears to be saturated and rendered opaque by what 
.must be an earlier condition of the same bodies. 



* Moleschott's " Untersuchungen zur Naturlehre," bd. vii, 6tesheft. 
f Virchow's " Archiv," bd. xxi, plate viii. 



THE FORMATION OF MUCUS AND PUS. 81 

These observations seem to show that the pus or mucus globule 
on mucous membranes is the material of young or renovated 
epithelial cells, arrested in its development at the earliest dawn 
of life, before it has assumed the form of a cell, when it is almost 
as unlike its destined final form as an egg is to a chicken. They 
seem to show that in this state it may be thrown directly off by 
the epithelium being broken, or it may pass into the substance of 
the epithelium. In either case it does not part with the low de- 
gree of life it has acquired ; but neither does it acquire a higher 
degree ; it goes on propagating, but nothing more. 

Both Buhl's and Rindfleisch's observations seem also to prove 
that pus-globules are not produced, or at least not produced only, 
by the degeneration of existing cells ; they are not tissue retro- 
grading into a lower form of life like fatty, amyloid, and similar 
morbid matter. Buhl's drawings especially exhibit the nucleus 
of the epithelial cell intact along with the newly-formed pus- 
globule. They differ, however, in one particular, that whereas 
according to Buhl the first pus-globule produced free in the cell 
increases itself by division, Rindfleisch assumes a splitting up of 
the whole contents of the cell according to the analogy of the 
egg-yelk. As Buhl's observations are made upon epithelium 
alone and Rindfleisch's upon areolar tissue also, and in one case 
the epithelium remained perfect and in the other was broken up, 
I can see no inconsistency in allowing both to be correct, and to 
represent the different behavior of growing matter under different 
circumstances. 

A very ingenious place has been selected by Junge* for the 
investigation of the growth of pus — viz. : the tunic of the aqueous 
humor in the eye. He caused inflammation by the application 
of a hot wire to the cornea of an animal, and was thus able to see 
what went on in the deeper parts of the eye without exposing the 
affected tissue to the air or any other extraneous agency. He 
was thus able to see the active growth of globules by division 
and subdivision so far as the formation of large masses. 

As the secretion on the surface of mucous membranes becomes 

* " Uber Eiterbildung," &c. : " Archiv fur Path. Anatomie und Physiologie," 
bd. xxii, heft 1, 2, p. 193. 



82 THE FORMATION OF MUCUS AND PUS. 

more opaque or "purulent," so the globules are more and more 
regular in size, rounder, and more like one another. In trans- 
parent mucus most of them are oval, with nuclei indistinct and 
various in number, while there are often lumps on their sides 
distorting the form. In creamy pus they are nearly all of a size, 
and present two or three well-marked nuclei. This is easily 
accounted for, if we admit that they are multiplied on the surface 
of the membrane. When first formed, they appear under violent 
and varying circumstances, different in degree every moment, 
and therefore are different in form ; but when once separated, 
they may go on multiplying under favor of nutriment and heat 
for several generations. Thus, like wild races of animals, they 
lose individual differences, and become more and more similar 
and uniform in characteristics. 

The formation of pus in deep-seated parts is, of course, not so 
easy to trace as on surfaces, and experimenters seem deterred by 
the difficulty of the subject. In all tissues where pus is found, 
its optical characteristics are the same as the fully-formed pus 
of mucous membranes : it presents globules all nearly of the 
same size, and with a pretty even amount of nuclei. This is its 
complete condition ; but what it is like immediately on its sepa- 
ration we do not know. We cannot trace it through a stage 
analogous to mucus. 

Of its previous condition, however, we may form a shrewd con- 
jecture. The same elementary substance which appears on, or 
rather in, integumentary tissues as the common material of the 
various kinds of epithelium, appears also as granular nuclei in 
other tissues — in the ganglia of nerves, in the brain, in the 
parenchyma of the liver, in the spleen, thyroid and thymus, &c. 
The same bodies occur also in the blood, where they have been 
termed " chyle-corpuscles" and " white cells." They are found in 
large quantities in the most recently formed, most quickly grow- 
ing, and most actively renewed component parts of the animal 
frame. In short, the most rational interpretation of this form of 
organic matter is that which represents it as the common material 
of all tissues in its earliest state of elementary life. And as that 
which was to have formed epithelium is cast off as the basis of 



THE FORMATION OF MUCUS AND PUS. 83 

the mucus and pus-globule, so that "which was to have formed 
hepatic parenchyma, nerve, or areolar tissue becomes pus, per- 
haps through some unsuspected transitional stage. 

In this account of organic forms in pus and mucus I have en- 
deavored to harmonize the contributions of several observers. I 
have done this mainly by omitting points of observation and 
deductions in which they differ from one another, and putting 
together those on which they agree. Their harmony also has 
been much assisted by translating into a common language the 
various terms in which they express the laws of life which their 
observations appear to exhibit. It is curious how often plain 
English reconciles difficulties. 



LECTURE V. 
THE FORMATION OF MUCUS AND PUS. 

Mucus and pus compared — Grades of loss of vitality in mucous 
membranes — Exemplification of these grades in smallpox 
pustules — Practical deductions from the various points com- 
mented on in the three lectures. 

(Third Lumleian Lecture at the College of Physicians, Lent, 1863.) 

In the vitalized forms which they present, we may consider pus 
and mucus as identical ; the pus-globule being merely the de- 
scendant more or less remote of the mucus-globule, and both 
retaining only that low degree of life which they originally 
derived from the body. The physical differences between the 
two depend seemingly upon the medium in which these vitalized 
forms are suspended. Neither in pus nor mucus are the contents 
of this medium constant in their proportion to one another ; no 
two analyses of pus or mucus are ever the same. 

Indubitable pus and indubitable mucus may be clearly defined 
as the two ends of a scale, between which there are innumerable 
gradations. The most transparent, stringiest, and least globular 
mucus consists principally of a peculiar animal matter, which is 
not albumen, though it closely resembles it. It is not coagulable 
by heat, and it contains more oxygen on ultimate analysis than 
albumen does. Sulphur also appears not to be one of its constit- 
uents. Until it can be found reducible to be considered a com- 
pound of some known intermediate substances, it is temporarily 
called "mucin." This word simply means mucus divested of 



THE FORMATION OF MUCUS AND PUS. 85 

those contents which are capable of another nomenclature and 
physical separation — as, for instance, epithelium scales, blood, 
the ammonia of decomposition, &c. The analyses are well known, 
being reprinted in every work of physiological chemistry, but 
shed little light, for the obvious reason that the substance ana- 
lyzed is hardly ever twice the same. 

Pus, on the other hand, contains a large quantity of albumen, 
and a large quantity of fat. A modification in the mode of the 
loss of health is characterized by the presence of fibrin, and cer- 
tain forms of defective vitality by casein being also found. The 
inorganic constituents of both seem to be the same as those of 
blood-serum with some of its water lost. Our diagnosis, then, 
of the morbid secretions of the mucous membranes should be not 
absolute — not that such and such a specimen is pus or is mucus — 
but comparative, that it is more or less purulent, according as it 
exhibits a greater or smaller quantity of albumen ; a fact easily 
ascertained by the degree of its coagulation by heat when diluted 
with water. And this is thoroughly practical and important, for 
it indicates the degree of loss of local vitality in the secreting 
membrane. Equally practical also and important is the observa- 
tion of the presence of fibrin and its amount. In large and 
overwhelming quantities we are familiar with it as occurring in 
the most serious deficiency of life consistent with life at all which 
we find in mucous membranes ; and there appears even in minor 
cases a close connection between its amount and the degree of 
deficient vitality or inflammation. During a severe cold in the 
head minute clots of spontaneously coagulating fibrin may be 
found in the secretion of the Schneiderian membrane, which, 
existing in large quantities, form the false membranes indicative 
of the serious poisoning of the system in diphtheria and croup. 

The phenomena we see on the mucous membranes are a question 
of degree rather than of essential difference. 

Loss of vitality, as shown in mucous membranes, seems to be 
exhibited in the following degrees : 

First there is an arrest of function. For example, from the 
impression of cold the Schneiderian membrane is temporarily 
deprived of its endosmotic force ; it ceases to absorb the water 



86 THE FORMATION OF MUCUS AND PUS. 

which is condensed on its surface from the breath, and that water 
drips from the nostrils. Or the stomach or intestines, from men- 
tal or physical causes, are deprived of their power of absorbing 
and digesting the fluid matters presented to them, and partially 
first excreted from them ; and these fluids may pass away by 
diarrhoea. Or the skin is chilled, and shows its deficient vitality 
chiefly in the deficiency of its most prominent function ; though 
it feels painfully, it cannot feel so delicately as it ought. In a 
vigorous person full life is soon regained : the nose recovers its 
natural degree of dryness ; the intestines absorb again before 
the fluids have passed from the body, and the temporary indi- 
gestion does not arrive at diarrhoea ; the skin recovers its feeling 
after a temporary painfullness. But we know that our invalid 
patients, whose vitality is low, are not so easily reinstated. 
Catarrh of various parts quickly and readily follows the action of 
physical agents. It is probable that in this least degree of injury 
the capillaries are contracted in area, and consequently the 
rapidity of their stream increased, by the action of the nerves. 
This phenomenon is wanting if the injury is greater ; in experi- 
ments upon animals the microscope does not detect it, if the 
reagent applied is powerful. 

2. A greater degree of injury is accompanied by a loss of 
elasticity in the capillaries. Their dilatation, and the consequent 
retention and stagnation of the blood in them, is familiar to us 
all, in both the living and dead subject, as " inflammatory con- 
gestion." 

3. This stagnation may be in isolated spots complete ; the 
blood-discs adhere together in rolls, as when removed from the 
body,* and block up the passage. Thus the arterial wave is 
obstructed in its course, and like an ocean swell shattered against 
a shore of rocks, becomes more evident to the senses as the well- 
known " throbbing." It is shortened and sharpened, but there 
is no evidence that it is strengthened ; indeed, the analogy I have 

* It is not necessary here to go into the question, so ably treated by Mr. 
Lister, as to the first origin of this evidence of death; whether the blood-discs 
adhere in consequence of their own idiopathic death, or in consequence of the 
withdrawal of the influence of the tissues, which normally keep them from 
adhering. 



THE FORMATION OF MUCUS AND PUS. 87 

cited, and the general fact of weakness being accompanied by 
quickened pulse, would seem to show that it is diminished in 
propelling force. 

In the mean time there is an accumulation of that constituent 
of the blood which most resembles in appearance the element of 
young growing tissue — the colorless blood-corpuscles. The blood 
is dark, indeed, to the naked eye, but under the microscope is 
seen to be made dark by being filled with these pale bodies, 
possessing a high refractive power. 

The loss of elasticity in the coats of the capillaries renders 
them more easily permeable by the contained fluid. Serum is 
poured out into the neighboring parenchyma, and joins with the 
swollen capillaries in producing " swelling." The loss of vitality 
in the blood-discs may be so complete that their haematin is dis 
solved in the serum, and we get the surrounding parts stained 
with it — as for a short time in typhus fever, and for a long time 
in syphilitic eruptions. Or the blood-vessels may completely lose 
their cohesion and be ruptured, allowing of haemorrhage. But 
in all this there is no new process, nothing which is not a direct 
deficiency of function. 

In solid structures this effusion is followed by an endosmotic 
current of the watery part back again into the circulation, leav- 
ing behind it the more solid and coagulable constituents. On free 
surfaces, covered only by soft open epithelium, the water and 
salts therein dissolved escape, forming the fluid of the mucus. 
The elements of new tissue, being there very copious to supply 
the constant demand for growth, ooze out copiously with the 
serum, and constitute the mucous globules. They are wasted 
elements of new growth, not themselves a new creation, or evi- 
dences of superadded life. 

How do these matters get through the coats of the capillaries ? 
There cannot be holes for their escape, or else the blood-discs, 
which are the smaller of the two, would escape also. Doubtless 
this is one of the great riddles of physiology. But the art of 
drawing is in a certain degree responsible for some of the diffi- 
culty which it presents to our minds. When we have no means 
of correcting by our other senses impressions made on the eye, 



88 THE FORMATION OF MUCUS AND PUS. 

we are too apt to consider everything with an outline as equally 
solid. The necessarily hard outlines of .the engraver express to 
us forms which may, for all the paper shows, be spheres of cast 
iron, whereas in truth they are as delicate as aerial clouds. Why 
may they not pass through tissues, mutually dissolving and dis- 
solved by the materials of those tissues ? Just as we see a stratum 
of fleecy cloud among mountains, or in Turner's pictures, disap- 
pear when it comes to a stratum of warm air, and reappear in the 
same form when it emerges on the other side. To get just ideas 
of nature, we must look upon solidity as a comparative, not as 
an absolute, quality. 

4. In a higher degree of deficient vitality the serum contains 
albumen and fat also exuded with it ; and this mixed with the 
multiplied globules constitute the fluid we call " pus." The albu- 
men and fat not only escape on free surfaces, but saturate also 
the tissues they escape through, making them more retentive of 
water than would otherwise be the case. Inflamed cuticle takes 
a much longer period to dry than normal cuticle. Langhans 
found that a piece of healthy rabbit-skin was crisp in three 
hours, but a piece of the same skin which had been inflamed 
during life took twenty hours to part with its moisture to the 
same extent.* It appears to be saturated with the nutriment 
which it has lost the power of employing aright. 

5. Pus formed as I have described is a soft and greasy lini- 
ment, capable of shielding the parts with which it lies in contact 
from foreign influences, which in their condition of lowered 
vitality would be noxious to them. It is more bland and less 
liable to decomposition than any artificial application ; for, laid 
on the healthy skin, it causes less irritation than even water. 
But under certain circumstances it becomes what we term 
ichorous ; and then it is corrosive, poisonous, and destructive to 
the neighboring tissues. Now, this cannot arise simply by the 
chemical decomposition of the pus itself in consequence of reten- 
tion ; because in a good many cases (as in cancrum oris, for ex- 
ample) it has not been retained so long as usual, but is thrown off 
ichorous and irritating as it is formed. But you may observe 

* " Zeitschrift fur Rat. Med.," R. iii, bd. xii, heft 2. 



THE FORMATION OF MUCUS AND PUS. 89 

that in all these instances of ichorous pus there is necrosis, mor- 
tification, ulceration, oy some other form of actual loss of tissue. 
Tissue may be formed, as in granulations, but it is being de- 
stroyed at the same time with abnormal rapidity. I cannot but 
think therefore that the ichorous nature of such pus may be due 
to its saturation with the organic acids which are the results of 
the decomposition, not of the pus itself, but of the melting tissues. 
Wash away this irritating pus, clean the sore, and that which is 
then formed often is quite bland and benignant. As pus differs 
from mucus, so ichor differs from pus in the nature of its acci- 
dental fluid constituents. 

The formation of ichorous pus exhibits a further stage of loss 
of vitality. The poisonous part of it seems to be peculiarly 
soluble, and capable of uniting with, and destroying animal 
tissues. Absorbed into the blood, it naturally destroys the 
vitality of the constituents of that fluid, causes it to coagulate in 
localized spots, and thus to give rise to the congestions and 
abscesses of pygemia. "When we reflect how easily ulcerations 
may arise in mucous membranes, and what an active surface they 
offer for absorption, we cannot be surprised at the frequency 
with which pysemic abscesses follow slight injuries, such as oper- 
ations on the bladder, crushing of calculi, typhous inflammation 
of the bowels — cases which seem of minor moment, but which 
certainly involve solutions of continuity, with consequent de- 
composition of tissue and the formation of ichor, in a situation 
very open to absorption. 

6. The formation of fibrinous coats on mucous membranes I 
have already shown not necessarily to involve destruction of the 
epithelium. Is the loss of vitality which causes it to exosmose 
through the capillaries in the fibrin itself or on the walls of those 
vessels ? Whichever it may be, such an exudation certainly is 
evidence of a great deficiency of life ; and, moreover, by the 
mechanical impediment it throws in the way of the functions, 
usually leads to further deficiency. 

These facts, so familiar to us all in our daily work, viewed 
thus in connection with one another, cannot fail to impress us 
with the feeling that the seeming activity of mucous membranes 
7 



90 THE FORMATION OF MUCUS AND PUS. 

in diseases is in truth a descending scale of loss of vitality. And 
this feeling must, I think, have great weight in our therapeutical 
dealings - with those diseases ; indeed, I cannot imagine anything 
of more practical importance to physicians and their patients. 

The influence of physical agents on mucous membranes which 
are throwing off mucus or pus, or are disposed to do so, is very 
different from what it is during their health. A degree of cold, 
which is borne with ease by them when in full vigor, causes a 
further arrest in their functions, and heat is equally badly borne. 
The action of oxygen, as contained in atmospheric air, is to the 
healthy tegumentary tissues invigorating and beneficial ; but 
when their vitality is lowered, exposure to it kills them still 
further, and may even alone prove fatal to the patient, as we see 
in the instance of extensive burns. 

I was lately much struck with the noxious influence of atmos- 
pheric air on the pyogenic skin in a case of confluent smallpox. 
At the period of the maturation of the pocks, when just preparing 
to begin drying up, they presented three grades, distinguishable 
by the following microscopic differences in their contents. In 
one sort the matter was of the consistence of thin lard, white and 
opaque. Examined under the microscope, it was seen to consist 
of epidermic scales, many of normal aspect, but some filled with 
granular matter hiding from view the central nucleus. In 
another sort the normal scales were few, the granular scales 
equaling them in number ; but more numerous than either were 
pus-globules of various sizes and of irregular shapes, as if bud- 
ding on several sides. In a third sort, taken from the very con- 
fluent parts of the eruption, there was nothing to be seen in 
general but regularly formed pus-globules of even size, and a 
number of highly refractive globules (of fat) among them. The 
fully formed pus was so copious that it overpowered the debris 
of epidermis, which was barely visible. These three classes of 
microscopic phenomena represented three grades of destruction 
which the skin had undergone from the effect of the variolous 
poison. In the first the epidermis was merely destroyed, and 
the materials for renewal were available for a new one. In the 
second to a slight degree, and in the third completely, these were 



THE FORMATION OF MUCUS AND PUS. 91 

converted into pus to a great depth. Consequently there was 
great risk of permanent destruction of the skin, or a scar. Now 
I found that the grade of destruction bore a direct ratio to the 
exposure of the various parts to the air. The most favored 
situations were the thighs, abdomen, and tongue, where the pocks 
of the first or less injurious kind were very numerous. Next 
came the legs and back, and then the hands and forearms. The 
face was the most purulently affected of all. The back (where 
the eruption was confluent) maintained its comparative immunity 
in spite of the cuticle being much chafed by the movements of 
the sufferer. You will notice that the most affected situations are 
those which are most exposed to oxygen and evaporation, which 
are life to the healthy skin, but death to it when diseased. 

On rational grounds, then, I think the practice of painting 
over the pocks in prominent and important situations with col- 
lodion, caoutchouc, or gutta percha may be fairly defended. In 
this way we do all we can to secure a local atmosphere of car- 
bonic acid — the normal atmosphere of internal tissues, — and to 
prevent the loss of vitality in the covered parts. 

More than this, I think we should be led to consider whether 
we do not sometimes err in applying too rigidly the theory of the 
universal wholesomeness of fresh air. Fatal cases teach us that 
it is bad for inflamed skins ; is it good for wounds ? is it good 
for abscesses ? is it good for inflamed lungs ? As physicians 
we have most to do with the latter case ; and I must say I find 
that few things contribute to the ease and recovery of my 
patients, so much as limiting the supply of oxygen in the atmos- 
pheric air by saturating it with watery vapor. I refer here not 
only to pneumonia, but to all catarrhal affections of the breathing 
apparatus. 

The stomach, again, is much benefited by carbonic acid. It 
naturally contains that gas, and some cases of deficient digestion 
appear to arise from its absence. Atmospheric air swallowed 
with the food, or by a pernicious habit, produces dyspepsia ; and 
nothing benefits that dyspepsia so much as solutions of carbonic 
acid in water. Our soda water, potash water, and litkia water 
derive their main virtue from the fixed air they contain. 



92 THE FORMATION OF MUCUS AND PUS. 

I believe that the only way in which carbonic acid is employed 
in surgery is under the form of yeast poultices, which certainly 
stay the progress of death in the skin quicker than most applica- 
tions. Were I a surgeon, I should like to try the use of the gas in a 
purer form as a healing agent for wounds, operative or accidental. 

Such an atmosphere of carbonic acid is to a certain extent 
secured to sore places by a layer of pus or mucus, which is satu- 
rated with that gas, and not very pervious to oxygen. It is a 
great defense against noxious agencies, and I think we are wrong 
to clear it away more than is necessary to comparative cleanli- 
ness and the patienfs comfort. We know how much lighter 
gonorrhoea is in the female than in the male, and one reason 
appears to be that the secretion is not constantly washed off the 
mucous membrane by the passage of the urine. Dirty people 
seem hardly to notice the existence of these discharges from the 
mucous membrane — they come and go of their own accord with- 
out causing any illness; while, on the other hand, cleanly 
patients are martyrs to their minor virtue and to their sensitive- 
ness, protracting and aggravating disease by constantly removing 
the defense which pus or mucus presents against oxygen and 
cold. Of course an exception must be made of cases where the 
pus is ichorous and poisonous in its. quality, when the sooner it 
is removed the better for the patient. 

On the principle of not too frequently cleansing away mucous 
secretions I should attribute greater advantages -than we are in 
the habit of attributing to opiates and other sedatives in pul- 
monary affections, where there is a copious bronchial discharge. 
Their obvious and immediate effect is to ease the cough; and 
some medical men are in the habit of speaking of that alleviation 
as if it were merely a convenient mask to conceal the morbid 
process which went on uninterruptedly. This easing of the 
cough, doubtless, takes place through the pneumogastric nerve 
being rendered less sensitive to the presence of the abnormal 
secretion, and so allowing it to collect in larger quantity before 
it is expectorated. I cannot but think this collection in larger 
quantities^ before expectoration is beneficial as a defense and as 
a curative measure. 



THE FORMATION OF MUCUS AND PUS. 93 

The idea which I have endeavored to inculcate, that an in- 
crease in the quantity of living tissues is by no means an evidence 
of an increase of their life or of their powers of life — nay, fur- 
ther, that it is rather an evidence of deficient life, cannot but 
have an important bearing on both pathology and practical 
physic. It is not a question of words, but of deeds. If inflam- 
mation be an abnormal increase of the vital powers of the tissues 
affected, then we cannot do better than employ the many agents 
which have a direct power of weakening life, a power which 
Boerhaave and Van Swieten believed was the only one the art of 
medicine could give.* If inflammation be an increase of vital 
powers, we should value our bleeding, our blistering, and our 
evacuants in accordance with the degree in which they reduce 
the strength. If, on the other hand, the phenomena of inflam- 
mation indicate direct deficiency of vitality, not only in the 
general system, but in the part affected, then we must make the 
chief end to be kept in view in our treatment the retention and 
increase of vitality. And when we employ the means I have 
named, we must look upon their debilitating action as an ugly 
fault unfortunately joined to some other virtue which they pos- 
sess, and must try to counteract the evil while we retain the 
good. 

Take for example the remedy blood-letting. Experience 
shows it to be beneficial in certain cases, so let us use it by 
all means. But all its benefits can be rationally traced to its 
mechanical hydrostatic action — to the taking away of so much 
fluid pressure which the weakened part is unable to bear. Let 
us, then, so apply the remedy that these mechanical phenomena 
should have most play, by making it as local and as sudden as 
we can, and by using it with a reference to what we want it to 
do. And all its evils can be also rationally traced to its physio- 
logical action — to its detraction of so much material of tissue 
from the circulation. Let us, then, when we use it for its 
mechanical advantage, counteract its physiological disadvantages 
by replacing to the best of our ability these materials of tissue. 

* " All that art can do is to weaken life." — Van Swieten's " Commentary on 
Boerhaave," vol. i. 3 106. 



94 THE FORMATION OF MUCUS AND PUS. 

Instead of designedly starving our patients when we bleed, let 
us feed them. 

We may reckon in the same way with other remedies less 
directly destructive than blood-letting. We should value them, 
not in proportion to their special evacuant power, for which they 
severally are classified as purgatives, expectorants, sudorifics, &c, 
but in proportion to the renewed growth of healthy tissue which 
accompanies their action. For example, Epsom salts and aloes 
are both purgatives; but take a case of anaemic intestinal cos- 
tiveness, and we know well that the more Epsom salts the patient 
is dosed with the worse she is, but that aloes will restore a healthy 
condition to the mucous membrane of the bowels, and gradually 
reinstate its powers. It is not in proportion to their purgative 
powers that purgatives are beneficial, and we can hardly there- 
fore consider that it is because of these purgative powers that 
they are beneficial. 

The action of cantharides upon the skin as a curative agent 
has been established by the common consent of many genera- 
tions. Is it the blistering and destruction and drain of organic 
matter set up by the epispastic which does the good, or is some 
other part of its action? Now in eczema and herpes, and in 
smallpox above all, we have an enormous amount of blistering 
and destruction of skin and drain of organic matter ; but instead 
of distant inflammation being arrested by them, or distant gene- 
ration of pus prevented, we often see it produced. In smallpox, 
the more pustules there are on the body, the more likely the 
patient is to have bronchial catarrh and pneumonia. Burns bear 
a still closer resemblance to the morbid process set on foot by 
cantharides; but the greater the extent of burn the more risk 
there is of internal inflammation. Then remark the stage of 
their action when blisters do good : their benefits are experienced, 
not when the destruction of epidermis is at its height, not when 
there is most serum and mucus and pus evacuated, but as the 
healing begins. Observe, for instance, a case of water in the 
chest under treatment: the level of the pleuritic fluid does not 
decline most rapidly when the blister on the surface is filled with 
serum, but when it is drying up and healing. Is it not, then, 
the growth of new cuticle which restores our patient? 



THE FORMATION OF MUCUS AND PUS. 95 

In reckoning the beneficial actions of blisters as evidence for 
the counter-irritant theory of therapeutics, we are apt to forget 
the cantharidin which is absorbed by the skin, and the direct 
action of which absorbed drug on the mucous membranes is to 
bring them to a more healthy state. It appears, when taken by 
the mouth, — for instance in chronic bronchitis, and sometimes in 
gonorrhoea, — to be a direct stimulant of their vitality. Blisters 
may be beneficial in this way quite independent of their more 
eye-striking effect. 

Perhaps the most powerful for good of all the agents added 
to the Pharmacopoeia of late years is oil. During the internal 
use of oil the pus-secreting membranes and tissues dry up and 
become healthy, and their heated, congested state is diminished. 
And the more readily assimilated is the form of oil, so much 
the more marked is this improvement; that is to say, the more 
we saturate the system with a basis of growth, with a material 
capable of being built up into new tissues, the less likely it is to 
throw off those tissues in a half-formed state. The easy digesti- 
bility of cod-liver oil to my mind more than accounts for its won- 
derful effects, and makes superfluous the chemist's aims to find 
iodine or any other drug as a constant constituent in it. The 
good we do by administering it is in direct proportion to the 
largeness of the supply of nutriment thus presented to the tis- 
sues, and bears 110 relation to any pathogenetic result^. 

In investigating the action of drugs, we are sometimes apt to 
look too far, and in our search for the mysterious to pass over 
the obvious. We are apt to bestow too little thought on the 
immediate action of these agents on the mucous membranes 
with which they come in contact. Quinine, for example, inas- 
much as it passes through the blood so far as to reappear in the 
urine, doubtless influences most tissues of the body; but still 
nine patients out of ten receive the greater part of the benefit 
accruing from the use of quinine by means of the augmented 
appetite and digestion which results from its presence on the 
mucous membrane of the stomach, not in the blood. It seems 
probable that the improvement in the vitality of pus-secreting 
parts which accompanies a course of quinine is due to the greater 



96 THE FORMATION OF MUCUS AND PUS. 

quantity of nutriment which this useful drug causes the mucous 
tract of the intestines to absorb. 

The influence of heat upon mucus is a suggestive fact. If 
allowed to get cold, the globules cease to develop the little life 
they have; but if kept at the temperature of the body, they 
continue to grow into pus in spite of the unnatural circum- 
stances in which they are placed under the microscope. This 
seems to explain how hot fomentations and poultices "favor 
suppuration," as surgeons say, in boils and abscesses. It ex- 
plains also why suppuration is usually more rapid in deeply- 
seated, well-covered parts than in exposed situations. But is 
it wise thus to "favor suppuration?" Yes, truly; for while 
we are aiding the vitality of the pus-forming material, we are 
also aiding the vitality of the surrounding tissue — we are ena- 
bling it to recover that perfect state in which it need no longer 
waste its nutriment by throwing it off in a semi-vitalized stage ; 
while at the same time the pus formed is the most natural, the 
warmest, the softest, and the least injurious substance we can 
apply to a sore tissue. 

The recognized benefit of moist warmth may, I think, sug- 
gest to us something more. When an animal submits to the 
periodical latency of the higher functions which take place 
during sleep, it instinctively seeks the warmest berth it can 
find ; it is instinctively careless about the supply of oxygen so 
that it can get heat. Beasts hide themselves in unventilated 
dens and burrows; man surrounds himself with blankets and 
curtains in a close bedroom, and not all the questionable argu- 
ments of busy philanthropists can persuade him to open his 
window at night. I suppose that instinct is hereditary expe- 
rience transmitted by generation from sire to son, and continu- 
ously increased through countless ages. It is not surprising, 
therefore, that its silent voice should beat out of the field the 
voice of argument, however loquacious. But I doubt if we phy- 
sicians listen for it carefully enough. In that state of deficient 
vitality which constitutes disease, we are sadly apt to leave to 
accident the duty of cherishing the weak life by warmth. In 
every hospital I enter, the wards are a great deal toe cold. 



THE FORMATION OF MUCUS AND PUS. 97 

Because their forefathers tried to keep the sick warm bj unwise 
methods, the public in the present day zealously oppose the better 
means of healthy warmth which new inventions provide. Can 
we be surprised at rheumatic patients falling into pericarditis, 
at fever patients having pneumonia, when house-visitors, vigor- 
ous and well fed, walk in from the park, and finding the wards 
smell of mutton-broth and poultices, order the windows open 
without compunction? Such things are; but they might be pre- 
vented if physicians would first convince themselves, and then 
the public, that an atmosphere and a temperature which is 
agreeable and wholesome to the healthy need not be either 
agreeable or wholesome to the sick. 

I have endeavored in these three lectures to point out the 
practical bearings of what is a limited though an important part 
of the phenomena of life. It is not indeed even the whole of 
that pathological state which we conveniently call inflammation. 
But I think no harm is done by pressing to results deductions 
from even the most limited observations, so long as we remember 
that they are limited, and so long as we do not forcibly bend 
other observations into coincidence with them. 



LECTURE VI. 
TYPH-FEVER. 

Case — Cause of fever — Why it affects some and not all — The 
virus acts slowly, and enters probably by the alimentary 
canal — Case showing the progress of fever-poison checked 
by emetics — Action of fever-poison on living organism — De- 
vitalizing power on blood — The first symptom of partial 
death is a rigor — Next symptom, pain — Loss of appetite 
which does not arise from defective metamorphosis — diar- 
rhoea, haemorrhage, and increased heat, all are evidences 
that disease is something less than life — The object of treat- 
ment is not the mere typh poison, but the interstitial death 
of the tissues — The touchstone of restorative medicine is its 
application — Use of emetics — Tepid sponging — Cold affu- 
sion removes but does not check the formation of heat — 
Supply of food — Hydrochloric acid — Alcohol — Local blood- 
letting — Principal difference between patients lies in the 
stomach — Two instances — Deduction. 

{Clinical, St. Marys, October 18, 1861.) 

You saw a case of continued low fever (or, as I shall call it, 
for shortness, Typh-fever) admitted four days ago, which pre- 
sents a good many points valuable for instruction. 

Charles P., aged 15, a shop-messenger, who has grown rapidly 
lately, and has been worked perhaps rather beyond his strength, 
stated on admission that he had felt ill, languid, and unfit for 
exertion during the last six weeks. The past fortnight Jie had 



TYPH-FEVER. 99 

come home every evening without any appetite for his supper, 
and had sat cowering and shivering over the fire. For three 
days he vomited all food taken, had diarrhoea, and pain in the 
belly. Cough also had come on with a stitch in the right side 
during inspiration, and he had expectorated transparent mucus 
with sooty specks in it. 

There were to be seen on the surface of the abdomen and 
chest upwards of a dozen dingy fever-spots in several stages, 
some entirely disappearing on pressure, some not. You found 
no pain or gurgling on pressure of the belly, and the diarrhoea 
was stated to have ceased. You saw the patient prostrate from 
great muscular languor and inability to stand, and a very weary, 
dull look in his eyes. His tongue was thickly coated with 
yellow fur; his skin was hot and dry; his pulse 104, small and 
sharp. His urine was high-colored, and deposited a copious 
yellow sediment, soluble by heat. The quantity passed during 
the next twenty-four hours after admission was fifteen ounces, of 
the specific gravity 1*020. Then you noticed that the right 
cbeek was flushed. The lower part of the right lung you heard 
was dull on percussion, and to the listening ear there were 
moist cracklings coarse and fine in it, and dry whistling sounds 
scattered about the rest of the lungs. 

The boy's mother stated that they lived in a healthy attic, 
dry and free from foul odors, and could in nowise account for 
the illness. 

Here is a sporadic case of one of the low continued fevers 
common in this metropolis, and which have received a great 
variety of names, according to variations impressed upon them 
by the epidemic temporary constitution of the air or the pecu- 
liarities of the individual. The two best-marked and best-known 
varieties are called "typhus" and "typhoid," distinguished by 
peculiarities of eruption, and we hardly ever get a case in 
London which may not either be classed as one or the other, or 
be represented as a transition between the two. In registration 
at St. Mary's we make the distinction, and often also in speak- 
ing pathologically of the cases. But in treating them I do not 
do so; and therefore in lecturing about treatment, which is the 



100 TYPH-FEVER. 

business of a clinical teacher, I have adopted a name which would 
include both, from its likeness would be generally understood, 
would not involve adhesion to any theory of identity or differ- 
ence, and have in addition the merit of shortness. When I speak 
of continued low zymotic fever I shall call it "typh-fever." 

The present case has been a good one for study, for it has 
presented all the most important symptoms, without the patient 
being so ill as to be unable to tell his story, or to make the 
repetition of it and the examination by pupils dangerous to him. 
I will call your attention to what you may learn from it. 

There is every reason to believe that one of the chief exciting 
causes of these fevers is a poison generated by decomposing 
organic matter and received into the body from without. To 
judge by its effects, it seems to be widely diffused through the air, 
especially in the neighborhood of its origin, in the air of sewers, 
putrid marshes, and crowded human habitations. If you are 
readers of popular sanitary literature, you are probably crop-full 
of the accumulated and decies repetita evidence of this fact. 
You are tempted to ask how it is, if the poison is spread so 
broadcast, that everybody does not get poisoned? You will 
wonder why it should get into the body of this boy, while you, 
really much more exposed to it, escape. But remember there 
are two things necessary to poisoning ; not only the poison, but a 
person apt to be poisoned. And, in point of fact, the latter is 
the most important element in the transaction. It is only on a 
predisposed body that a morbid poison acts. Most likely we are 
all constantly taking in minute doses of the poison which is the 
exciting cause of these continued fevers, and can digest, oxidize 
it, or otherwise render it harmless under ordinary circumstances. 
But should some epidemic influence or exceptional deficiency of 
vitality rob us of the power of doing so, then we suffer the 
effects, and have typhus or typhoid fever, as the case may 
happen to be. There was reason enough for this boy being the 
victim, while others escaped, shown in his recent rapid growth 
and in his strength being overtasked by his work. The exhaus- 
tion of vitality allowed the poison to do its work. 

Besides this purely foreign mode of generation of the poison, 



TYPH-FEVER. 101 

it would appear capable of being produced within the body itself 
— out of its own substance — idiopathically. At least such a 
closely similar train of phenomena follow, where an external 
origin would seem a forced interpretation of nature, that we can 
hardly help coming to the conclusion I have stated in the last 
sentence. Thus a typhous state follows severe and disorgan- 
izing wounds, where all noxious foreign influences have been 
cautiously shut out; and mere climatic agencies, such as the 
unwonted heat of the sun, overwork, chills, damps, and espe- 
cially a combination of these circumstances, will bring on the 
well-known "febricula," perhaps of only a few days' duration, 
perhaps protracted ftito or (as some word it) "changing into" 
a regular typhus. 

I speak of the exciting cause of fever as of a material ponder- 
able substance for the sake of convenience. But I do not wish 
to exclude the possibility of its being an immaterial power or 
force, like light, heat, electricity, or sound, are held to be. If 
it is so, it is like tnem associated with ponderable matter, and 
becomes known to us only by means of such association. We 
speak of a thunder-cloud causing certain phenomena, although 
we know it is the electricity of the cloud which does so; of the 
sun burning us when we mean the heat of the sun; of a cannon 
deafening us when we refer to the vibrations of the air acting 
on our ears. And so we may speak of the poisoning power as 
a part of that modification of matter to which it is joined, in 
spite of that modification of matter possibly existing in* a similar 
form (chemically speaking) without being joined to it. 

Observe how slowly the power acts in some cases. Our patient 
is upwards of five weeks ailing before any of the distinctive feat- 
ures of his fever show themselves, and then they creep out one 
by one. The time is not usually so long, especially during epi- 
demics, but you may detect it in the history of almost every case. 
And you ought to notice it, because from some systematic works 
you might be led to thinking that a continued fever was easily 
to be measured by days and hours from the very moment of in- 
vasion. This is impossible in practice, and would be of little use 
were it possible. 



102 



TYPH-FEVER. 



I rather incline to think that the most usual path by which 
the virus enters is the digestive canal, in cases where it is be- 
gotten of decomposing organic matters foreign to the body. It is 
probably mixed with the saliva and carried down to the stomach, 
where it possibly may increase and multiply in the gastric mucus. 
During severe epidemics it has been observed that those who 
smoke or chew, especially if they spit out the saliva instead of 
swallowing it, are less liable to be attacked.* And at an early 
stage, even after the virus has begun to act upon the system, the 
fever may be stayed by emptying the stomach, and thus prevent- 
ing the whole dose being taken up. Those who have watched 
my practice will have witnessed several instances of the success 
of this treatment; they will have seen the fever cut short, and 
convalescence entered upon immediately,, with its characteristics 
of painless weakness and emaciation gradually passing away. 

One case last autumn gives me the opportunity of putting on 
record that the influence of the remedy is not merely apparent 
or accidental, but that it really removes an essential part of the 
disease. W. S., a robust lad aged 15, came into the hospital 
September 5, 1860, with hot skin, rigors, excessive muscular 
languor, pain in the back, limbs, and head of four days' duration, 
gurgling in the right iliac fossa, and rose spots. For the first 
twenty-four hours he had no medicine, and the urine was kept 
and analyzed. The result exhibited the following quantities of 
its various constituents daily excreted :-— 

Grammes. 



















' 




Date. 


1 d » 

'■Sis s 


1> 


03 


!5 

< 

o 


o . 


1l° 


•a 








p.g 


S3 


"£ 


2t 


&< 


z< 








02 & 




& 


r£OQ 










a S 








O 




P-. 


Sept. 6, 


1860. . . . 


1000 


1-027 


50-63 


•43 


•25 


3-48 


3-24 



Then an emetic was administered, and coincident with a uni- 
versal remission of all the symptoms, the urine exhibited the 

* Mr Catlin, of American-Indian celebrity, attributes the comparative freedom 
of his wild friends from malarious influences to their being taught as infants to 
sleep with their mouths shut, and to their being prevented by etiquette in after- 
life from ever opening them, except for eating or speaking. 



TYPH-FEVER. 



103 



following remarkable change in the amount passed during the 
next five periods of twenty-four hours: — 



Grammes. 





.s i 






H3 


o . 





.2 


Date. 






5 


•5 






o . 
o-5 






CO fec 










^ t 




a S 






p 


o 




Ph 


Sept. 7 


530 


1-028 


29-3*7 


a trace 


0-79 


1-97 


1-14 


Sept. 8 and 9 ; mean of 
















two days' urine mixed 


770 


1-016 


14-79 


0-037 


2-68 


1-008 


0-72 


Sept. 10 


1200 


1-011 


18-42 


0-090 


4-20 


1-34 


0-32 


Sept. 11 


1320 


1-006 


16-71 


a trace 


4-62 


0-#6 


0-71 



Now, the contrast between these specimens of urine is exactly 
that which is found between the urine during typh-fever and the 
urine during convalescence. In the first there is evidence of 
destructive metamorphosis going on with extreme rapidity ; in 
the latter the destruction is overtopped by renewal. . And this 
change into convalescence was most strikingly marked as due to 
the operation of the emetic. When we see so often the imme- 
diate consequence of one dose of so simple a remedy, it is difficult 
to avoid the conclusion that its benefit is purely mechanical, and 
that it acts by removing from the mucous membrane of the 
stomach a poison only partially absorbed and still adherent to it. 
Another reason for guessing that the gastric mucous membrane 
is an early if not the earliest recipient, is that it early exhibits 
such special phenomena as usually accompany the ingestion of 
an unwholesome material. Spontaneous vomiting is very gener- 
ally found in the first stage of the attack (as you have observed 
in the patient under consideration), and seems to offer a pre- 
sumption that the part which is then most feeling the effects of 
the poison is that organ which most resents it — the gastric 
mucous membrane. Such is the evidence by which I have been 
led to believe that the exciting cause of typh-fever enters usually 
by the digestive canal — valeat quantum. 

When the poison has once gained admission and is diffused by 
means of the circulation through the system, its effect is to 



104 TYPH-FEVER. 

destroy the vitality of a considerable amount of the organic living 
matter with which it comes in contact. The destruction is inter- 
stitial, not local — I mean, it does not kill wholly a certain spot 
which it touches, like sulphuric acid, but it kills only certain 
constituents of the tissues. The destruction is also partial, not 
entire — the organic matter is by no means utterly disorganized, 
but only brought down to a less vital, less organic condition. It 
may be traced easiest in the changes found in the medium by 
which it is diffused. The blood, the common thoroughfare for 
distribution of good and evil to the tissues, is seriously changed. 
If you examine it under the microscope you will find that the 
normally-shaped red disks are diminished in numbers as compared 
with what pathologists call " melanosed" corpuscles, that is to 
say, dying or dead disks, shriveled and small, of a dark color, 
with black specks in them, and with gimped edges. In bad cases 
these are unable to range themselves in rolls, as healthy blood 
does when it coagulates ; they seem to have scarce any attraction 
for one another and lie in amorphous heaps. They dissolve easily, 
in the serum and form with it a red fluid. Yon may trace this 
dissolution in the dusky stain which the blood communicates to 
the skin in typh-fever. 

The poisoning apparently goes on very gradually in some 
cases, and quicker in others. You heard from this boy that he 
was five weeks ailing before he gave up work. There was an 
imperfect renewal of the body, shown by languor after exertion 
and by loss of appetite or deficient demand for new material. 
But destructive assimilation was not checked, there was no im- 
pediment to the carrying off of the effete tissues by excretion. It 
may be that in a great many cases the disease, the partial death, 
stops here, the destroyed tissues and their destroyer together are 
disorganized, and reduced to. their elements and pass away. 
The idea is incapable of proof, but it would account for a vast 
number of those mysterious languors, unclassified, unnamed, and 
often unpitied, which distress patients and puzzle doctors. 

It is a characteristic of this sort of virus to poison mainly the 
nervous system. The fevers it produces get their name from 
thence — rv^ = a smoke or mist overclouding the instrument of 



TYPH-FEVER. 105 

connection between body and mind. In no other diseases of equal 
curability is it so much affected. When therefore the poisoning 
has reached a certain pitch, and that not a very high pitch, early 
in the disease, the nervous system takes notice thereof, and ex- 
presses itself in its most common mode of taking notice of partial 
death, namely, by a shivering fit. Any severe injury to the 
body, a stretching of fibrous tissues, an operation, the fear of 
an opinion, the absorption of destructive* drugs, such as antimony 
for example, will cause more or less of a rigor in proportion to 
the sensitiveness of the individual. And thus also in zymotic 
fevers, when the intestinal death of the neutral constituents of 
the body arrives at a certain degree, there follows a rigor. This 
rigor recurs from time to time at uncertain intervals, but gen- 
erally about once a day, and most commonly in the evening, as 
the mother remarked in the case which forms the text of my 
lecture. 

Then commences another symptom of partial death — pain. 
This boy described his head, his limbs, and his back as aching all 
at once. That is to say, wherever there was most tissue with 
sensitive nerves in it, there was found pain, indicating the 
diseased state of that tissue. Now this aching is a symptom of 
the earlier, rather than of the more advanced stages of typh- 
fever ; not because there is in the latter less death, but because 
then the nervous system becomes partially dead too, and does 
not feel so acutely ; while in the former it retains most of its 
normal sensibility. 

Observe that our patient tells us of nausea and loss of appetite, 
which diminished the food eaten — of vomiting, which rejected 
the greater part of that diminished food — and of diarrhoea, 
which carried off the remainder scarce digested at all. Yet in 
spite of all, the amount of solid matter passed from the kidneys 
is fair ; the specific gravity of the fifteen ounces of urine passed 
in the twenty-four hours is 1-020, which is a good deal for a 
person not in strong health. The metamorphosis, therefore, of 
the worn-out tissues into urea and salts is active ; there is a con- 
tinuous destruction of them in spite of the defective supply. 
This goes on so long as the poison lasts in the body ; but when 
8 



106 TYPH-FEVER. 

it is got rid of, the destruction ceases ; no more of the tissue is 
metamorphosed than is required to make room for new material, 
and the specific gravity of the urine falls during convalescence. 
This may take place very suddenly, as in the instance I gave you 
of a fever cut short by an emetic ; but in general the alteration 
is more gradual. * 

I have mentioned the large amount of urea, in proportion to 
the nutrition, contained in the urine of typh-fever, which is 
rendered evident by its high specific gravity. There is also an 
increase very evident to the naked eye in another constituent of 
some importance, the colored organic material, which gives the 
secretion its ordinary hue. You saw how dark this boy's water 
was, and how deeply it stained the vessel from which I poured it 
on a piece of white linen. We have great reason to think that 
there is a close alliance between this substance and whatever it 
is which gives the fed tint to the blood-disks, and that its excess 
depends on excessive destruction of those important little living 
particles. 

The sulphuric and phosphoric acids combined with bases, 
which form a necessary part of urine, do not in fevers follow the 
lead of the urea ; their amount is less than in health. Whether 
this is due to the destructive metamorphosis taking less effect on 
the chief tissues containing sulphur and phosphorus, than it does 
on the blood and muscles, is doubtful. Dr. Parkes suggests that 
perhaps a third of the normal sulphates and phosphates of the 
urine are derived directly from the food, and not from the meta- 
morphosis of tissue ; and therefore that their diminution in typh- 
fever may be owing to the starvation, while the amount which 
still remains represents a fair proportion of destruction.* 

The chlorine, in the shape of chloride of sodium, is also in 
small quantity, but not so deficient as to lead us to suppose that 
the metamorphosis of the chlorinated materials of the body does 
not go on, or that there is retention of them in the fluids. The 
great quantity of chloride of sodium taken as food, and directly 
mixing with all the fluids, again brings in difficulty. And another 
is thrown in our way by the frequency of intercurrent pneumonia, 

■* Parkes " On the Urine," B. ii, part iii, sect. 4. 



TYPH-FEVER. 107 

which itself causes a retention of the chlorides naturally excreted 
from the kidneys. This youth, for example, has a little pneumonia, 
and we could not, therefore, say if absence of chlorides in his 
case were due to that inflammation or to typh-fever. In other 
cases our impediments to knowledge are diarrhoea or colliquative 
sweating, which carry off chloride of sodium. 

The diarrhoea so frequent a companion of continued fever is a 
further evidence of death in the blood. Let the .fluid fever stools 
be set aside in a tall glass, and you will see them shortly sepa- 
rate into two parts ; the higher one a half-transparent serum, in 
which float epithelial scales and crystals of ammonio-magnesian 
phosphate ; the lower stratum a greenish-black flocculent pre- 
cipitate. This last has no smell of bile, nor is bile to be found in 
it by chemical tests ; but it contains broken-up blood-disks and a 
great quantity of dark, granular coloring matter — it is just like 
blood altered by the secretions of the bowels. And very often 
when you let the stools separate in this way, and look at them 
by transmitted light, you will see a visible sanguineous tinge in 
them, and blood mixed with mucus is visibly passed from the 
bowels. Blood, too, is not unfrequently spat up with the mucus 
from the lungs, and drips from the nose; and in bad cases the 
dried-up mucous membrane of the mouth cracks, and exudes the 
sanguineous serum on the surface of the tongue, producing the 
" dry, brown tongue" characteristic of severe fever. All these 
prominent symptoms call your attention to the interstitial death, 
the lessened life of the body. 

The increased heat in fever is to the careless observer rather 
adverse to the doctrine which I have advanced, that all disease 
is an evidence of diminished vitality. And in truth it requires 
some thought to see why it is not a conclusive objection. But 
an answer to the idea of an augmentation of heat being neces- 
sarily an augmentation of life is afforded by the fact of many 
recorded instances of the increase of corporeal' warmth having 
taken place in corpses actually after full death ; so that, dis- 
carding at once the notion of its being a proof of vitality, we may 
try and trace what causes, really rather to be associated with 
death, may give rise to it in the cases under our eye. In the first 



108 TYPH-FEVER. 

place, in fever you have a diminution of the evaporation which 
takes place from a healthy skin, and which acts as a powerful 
refrigerator, as any physiologist who has perspired knows full 
well. The dormant dry skin does not do its cooling office. Then 
in the second place, there is a much larger quantity of dead 
matter to be evacuated, and the destructive metamorphosis of 
this dead matter, the semi-vital chemical destruction, raises the 
temperature, as all chemical solutions do. Wherever metamor- 
phosis is rapid, the temperature is raised. But this metamor- 
phosis alone, this passage of living into inorganic matter, cannot 
be called an increase of life, inasmuch as it indicates an advance 
of death. It is necessary, may be, to the removal from the body 
of poisoned ingredients, and is so far an advantage, but still it is 
an indication of the quantity that is poisoned. 

Such are some of the most prominent consequences of the typh 
poison in the human body. 

You may call to mind, very likely, warnings I have given you 
against the old humoral pathologist's doctrine of a materies 
morbi, which was looked upon as the disease, and which he thought 
he has done his duty by endeavoring to eliminate. " Surely," 
you will say, " this which you have been describing is a most 
typical materies morbi ; if I evacuate this, I cure the disease." 
Not so fast — the bullet which enters the soldier's ribs is a ma- 
teries morbi, — have you cured the disease when you have 
extracted it? Nay, more — suppose the bullet passed right 
through the chest and went out on the other side, would you 
consider the disease gone ? No, the typh poison is not the 
disease, any more than a bullet, or sulphuric acid, or opium is a 
disease, though each may be a material cause of disease. The 
partial death which these agents cause is the disease — is that 
which requires to be treated, and must be the chief point for the 
physician's consideration. 

Here let us bring our doctrines to their touchstone — bedside 
application. The physician should ask himself, what vitality is 
wanting, and where ? And, how shall I easiest supply it ? 

In the first place, if he sees the case early, almost the only 
thing he notices is the lowered vitality of the stomach — how badly 



TYPH-FEVER. 109 

it digests its food, and how it loathes its usual work. He con- 
jectures that its function is arrested by the presence of some 
poison, and he empties it with an emetic. In many cases brought 
under treatment early in the disease, this cuts it short at once, 
as I told you in a former part of the lecture, and as you have 
occasional opportunities of observing in the wards. 

Secondly, supposing he is too late for his coup de main, he re- 
marks that the skin is hot and dry, in a great measure from 
deficient perspiration and evaporation on the surface of the body. 
He undertakes to supply this want by an artificial moisture. He 
sponges the whole person over three or four times a day with 
tepid water, to which the nurses here generally add some dis- 
tilled vinegar to make it more agreeable. The relief given is 
most sensible and immediate ; but of course it soon passes away, 
as changes of temperature are in their very nature temporary. 
It must therefore be frequently repeated. 

Cold affusion is sometimes spoken of, both by opponents and 
advocates, as " checking" or " arresting" the febrile heat. This is 
•apt to give you a wrong notion. If it really arrested the meta- 
morphosis which is the cause of that heat, it would be obnoxious 
to all that could be said against it. Bat in fact it no more " ar- 
rests" or " checks" the heat than emptying the bladder "arrests" 
the secretion of urine. A few moments' thought will show you 
that what it does is to remove the heat from the external surface ; 
and if it affects the cause of heat at all, it would rather encourage 
it by making room for more. 

If the attendants have sufficient leisure to attend to an opera- 
tion which consumes a good deal of time, it adds very much to 
the comfort derived from the sponging to anoint the body with 
some softly scented olive oil. This supplies the place of the 
arrested sebaceous follicles, and softens the skin for the absorp- 
tion and exhalation of water. It is a mistake to suppose that oil 
and water are at all inconsistent or incapable of mixing in the 
substance of living tissues. 

Where there is pneumonia in fever, or where the patient has 
recently had acute rheumatism, I confess I am somewhat cautious 
about the employment of aqueous affusion. It sometimes chills 



110 TYPH-FEYER. 

the chest and causes an attack of pleurisy on the inflamed side, 
or pericarditis. Besides which, in the case of pneumonia, it 
interferes with a plan I have of keeping a large poultice outside 
the affected part, and which I find so beneficial that I do not like 
to omit it. For this reason sponging was not ordered for the 
present patient. 

Thirdly, the physician sees that a large supply of nitrogenous 
material must be wanting. The nitrogenous tissues are devital- 
ized, are running away in a disproportionate excretion of urea 
and other organic compounds, and nothing is taking their place. 
Shall he act antagonistically, and give some drug whose tendency 
is to stop the passage of urea by the kidneys ? I do not know 
exactly how he would set about it ; but I do know that if he 
succeeded, he would do positive harm ; for the very worst cases 
of fever are those in which metamorphosis is active (as shown by 
the heat), while the excretion of urea is arrested (as shown by 
the lightness of the urine) ; they resemble cases of ursemic poison- 
ing from diseased kidneys. The other principles of treatment 
which I noticed in my introductory lecture of this session* would' 
not perhaps be so directly injurious, but common sense would 
still allot the palm to restoration here. Let it be your chief aim 
to supply that which you clearly see is passing away — nitrogenous 
tissue. 

But how will you supply it ? Solid food would in all proba- 
bility be vomited, from the unbearable loathing it excites. If not 
vomited, it would lie for some time a mere foreign matter outside 
the mucous membrane of the digestive canal, and then pass away 
by diarrhoea, with much flatus and fetor and much disengage- 
ment of gas during putrefaction. Your beef-steak might as well 
have been originally thrown down its final destination, the water- 
closet ; to which it passes putrid though undigested. Neither is 
it wise to fill the stomach with large quantities of victuals, for the 
same result follows. No "meals" must, therefore, be allowed; 
and prudence suggests the giving in their place yerj small doses 
of nitrogenous aliment very frequently. These pass over the 
irritated stomach unconsciously, and are taken up gradually by 

* Referring to Lecture I of the former edition. 



TYPH-FEVER. HI 

the intestines, requiring but very little to make them fit for ab- 
sorption. The suitablest food is that which is naturally supplied 
to the weakest stomach. The feeble digestive organs of babies 
can assimilate milk, and milk forms the most appropriate nourish- 
ment for the debilitated viscera of the fever patient. By giving 
two or three ounces every hour you may get down a quart and a 
half per diem. Bat in ordinary instances, every two hours is 
often enough, and that period is adopted for the boy before us. 
If there is sufficient acid left in the stomach to coagulate the 
casein into clots, and cheesy lumps are rejected by vomiting, as 
happens sometimes in milder cases, you may guard against this 
by adding liquor calcis or soda-water to the milk, or you may 
supply its place by beef-tea. But it is the lumping of the cheese 
into solid masses that it is desirable to avoid, not the acidifica- 
tion, which is beneficial. If the patient takes thus a good supply 
of milk and beef-tea, not only is the imminent danger of death 
by starvation avoided, but the emaciation which follows during 
convalescence is much less extreme, and the dangers in its wake 
less formidable. 

Eggs are a highly nutritious food ; if taken raw, and diluted 
with milk or water, they are quickly absorbed. But should they 
be delayed and putrefy, the products of their decomposition are 
peculiarly injurious : the sulphuretted hydrogen and ammonia 
evolved are poisons to the intestines. I should recommend you 
to avoid eggs till convalescence has restored the gastric powers. 
The same objection does not lie against milk, the lactic acid 
arising from whose decomposition assists in the solution of the 
casein. Sour buttermilk is by no means to be despised as a 
food. 

Fourthly, the physician should turn his attention to the phar- 
macopoeia, and consider what he can cull from thence which will 
be of service. 

You have been taught in the systematic course on medical 
pathology, that ammonia, which is always being formed and given 
off from the animal body, is found much more abundant in certain 
conditions than in others, and that these conditions are those in 
which nutritive metamorphosis or growth was deficient as com- 



112 TYPH-FEVER. 

pared with destructive metamorphosis, or those in which there is 
retention in the blood of the products of that destructive meta- 
morphosis. Thus, more ammonia is found in the breath after 
toil than after rest ; more than usual in those who hurt their 
digestion by smoking tobacco; a great deal in ursemia, where the 
urea cannot escape by the kidneys ; but above all in typh-fever 
is this exhalation of decay noticeable, as you will find in Dr. 
Richardson's valuable work on the coagulation of the blood,* 
where the phrase " super-alkalinity of the blood" is applied to 
this condition. Dr. Richardson goes so far as to attribute to this 
super-alkalinity the special typhoid symptoms, and to suggest 
that the absorption of ammonia in excess may intensify fever in 
those who contract it from exposure to decaying organic matter, 
or human exhalations. He supports his hypothesis on the ex- 
periment of inducing the symptoms, or something resembling 
them, by the injection of ammonia into the veins of an animal. 
The word " super-alkalinity" is expressive, and quite unobjection- 
able, so long as it is .understood that the superabundance is not 
absolute, but comparative. For it is not shown that there is more 
alkali in the body than there ought to be, but more than there is 
acid to neutralize. " Sub-acidity" would be a synonymous term, 
and would be more suggestive of the means we have at our dis- 
posal for remedying the defect. 

Very difficult indeed would it be for the eliminator to get this 
alkali out, but it is easy for the restoratist to get acid in. The 
acid I have always given is hydrochloric, and you consequently 
see on this lad's card — " 1^. Acidi hydroehlorici diluti fflxx. 
syrupiZ}., aquae 3j. alternd qudque hord sumat" 

Rich patients like a little more sugar, but I have not found 
them approve of the syrup of mulberries and barley water, in 
which more elegant vehicle the late Dr. Maton used to give 
muriatic acid in fever. They say this is mawkish, and prefer the 
•cheaper form, even on the score of taste. But it is still more 
approved of for its beneficial effects. This boy said to-day of his 
own accord, he hoped I should continue the draughts, they made 

* Richardson on the "Cause of the .coagulation of the blood," Appendix I. 
(Edit. 1858.) 



TYPH-FEVER. 113 

him "feel so much stronger," meaning to express a sensation of 
relief to the wearisome languor of fever. In mild cases the tongue 
begins to clean immediately, the thirst and diarrhoea much abate, 
and the repugnance to food is diminished. 

In a clinical lecture at this hospital in January, 1858,* I gave 
the details of the first dozen cases treated on this plan, and as 
you are a different audience from that which heard me at that 
time, perhaps I may be allowed to repeat the sentences in which 
I then tried to interpret the beneficial consequences : — " What 
blood, when analyzed, comes nearest in its altered proportions 
to the blood in low fever ? Is it not that of scurvy "and purpura ? 
There is the same excess of blackened (melanosed) blood-disks, 
the same deficiency of neutral salts and organizable (coagulable) 
lymph. Everybody treats these chronic affections with acids, 
and why not also an acute affection which' corresponds with them 
in one point at any rate ? As to the particular acid employed, 
muriatic certainly deserves to be tried before others — first, 
because it is such a large constituent of the body that it -might 
almost be called a food instead of a medicine ; and secondly, 
because it is such a powerful arrester of the decomposition of 
animal matters. Pour it into a sewer, and you destroy the 
miasma. May it not in the body stop that miasma from poison- 
ing the tissues ?" 

The allusion in the last sentence is to chlorine as a disinfectant. 
But I now doubt if there is sufficient evidence of the benefit 
derived from the hydrochloric acid being due to this property. 
About sixteen years ago, I employed chlorine water as a medi- 
cine in fever at the Chelsea Dispensary ; yet I was not en- 
couraged to carry on the treatment by tracing any benefit to it. 
Whether the chlorine which can be introduced in this way is not 
sufficient in amount (for it must be very dilute, or else it will 
induce choking), or whether it is really useless, I do not know ; 
but the inconvenience caused me to leave off its employment. 

Dr. Pereira in his " Materia Meclica" speaks slightingly of the 
use of hydrochloric acid in putrid fevers, and implies that it rests 

* Printed in the -'Lancet," January 30 and February 6, 1858, and partly re- 
printed in the next lecture but one. 



114 TYPH-FEVER. 

solely on exploded theoretical propositions. He should have 
noticed that Boerhaave and Van Swieten recommend it, and that 
Sydenham used sulphuric acid in these forms of disease as an 
antiseptic drug. And these were men not easily led into erroneous 
practice by a prevalent theory. To their experience I can add 
my testimony, for I have employed the plan above described in 
every case of typh-fever since the summer of 1857, and have had 
yearly more and more reason to speak well of it.* 

Dr. Pereira, in afterward speaking of its use in dyspepsia, 
gives as a reason for its employment therein, that first, "it is a 
constituent of the healthy gastric juice ; and, secondly, when 
mixed with mucus, it has a solvent or digestive power in the case 
of various articles of diet." Is not this as much a reason for 
giving it in acute cases as in chronic ? 

Whether, then, as Sydenham seems to have thought, any other 
acid would do as well as the hydrochloric, I cannot say, but it 
forms so large a constituent of the body combined with alkali in 
the blood and tissues, and free in the solvent juices, that it 
appears peculiarly suited to the purpose on restorative prin- 
ciples. 

As to the use of alcohol in fevers, I am guided almost entirely 
by the condition of the nervous system. If there is very com- 
plete prostration and delirium of a low muttering character, it is 
required. A tremulous state of the muscles, marked especially 
by a quivering of the hands and fingers, is a good test of the 
necessity for it ; and so is the sharp, weak, unequal beat of the 
heart. All these indicate that the nervous system is feeling very 
sensitively the destructive metamorphosis going on, and has its 
power lowered by its sensitiveness. Then is the opportunity for 
the powerful anaesthetic alcohol, which in severe cases you see 
me order without scruple, but which I do not rank as part of the 
necessary methodus medendi of fever, and have not yet ordered 
for the lad we have been prescribing for. Above all, I would 
caution you against employing it as a substitute for the treat- 
ment which I have been describing. Wine may be useful as an 
adjunct, but never must it take the place of the true restoratives. 

* This yearly growing experience is put into numbers in a subsequent lecture. 



TYPH-FEVER. 115 

There is, though, another of the exceptional methods of treat- 
ment, which has been employed with utility in this case — the 
local abstraction of blood. The boy had congestive pneumonia 
of the lower part of one lung, and I did not hesitate to cup him 
beneath the scapula on that side. And not unfrequently when 
there is pain in the right iliac fossa, with diarrhoea and tenesmus, 
I put leeches on the belly at the seat of pain. You watched the 
dullness of percussion rapidly pass away from the lower lobe in 
our patient here ; and you will often see an equal relief to the 
abdominal congestion by the same agency. 

But you will cry out that I am sadly inconsistent. I am 
feeding up the patient with one hand and taking his pabulum 
vitae with another. The reproach is just in a certain sense, but 
that a very limited one ; and, in fact, may be leveled against 
half the operations of daily life. We are constantly suffering a 
small loss for the sake of a greater gain. And I think the loss 
of a little blood is practically of no moment at all compared with 
the advantage of securing a freer circulation through the lungs 
or a diminution of congestion in the intestinal canal. Do not be 
led away by the superficial notion that blood is blood, and blood 
is life. That is not true, for blood varies immensely in its com- 
position, some being very valuable, and some worthless. To 
lose a portion of the half-dead circulating fluid of fever is but 
little loss, and that little loss is amply repaid by the additional 
nutriment which a small blood-letting will enable to be absorbed. 
The deficiency is soon made up again under a restorative system 
of treatment. 

In the sequelae of low fevers, more than in any other diseases, 
the great difference between one patient and another as respects 
their power of recovery, lies in their stomach. There is a girl 
of four years old now in Victoria Ward, who was admitted on 
the 2d of September for rose-spotted fever, which had come out 
during the concluding week of August. She passed through the 
fever pretty favorably, but for the last seven weeks has had a 
succession of most formidable abscesses in the back, the cervical 
glands, the internal ears, and the parotid glands ; yet, in spite 
of the exhausting effect of the large discharge of pus from these 



116 TYPH-FEVER. 

spots, she has continued advancing in convalescence, she has 
gained flesh and muscular power, so that now she can sit up. 
For this happy result she has to thank a most wonderful appetite, 
which never seems satisfied, even with an amount of food which 
is large for an adult, and which she delights to wash down with 
wine and porter. No tonics seem of so much use to her as an 
extra snack at physic time. 

The most striking recovery from these pysemic ahscesses after 
fever you witnessed last year in a girl of sixteen (E. A., admitted 
September 28, 1860). She had very putrid fever, accompanied 
by hsemoptysis, epistaxis, and bloody discharge per vaginam. 
She got well of her fever by the help of hydrochloric acid and 
wine. But as she became convalescent in the third week of Oc- 
tober, she began to have large boils in the head ; these were 
followed by abscesses running on into sloughing sores on the 
back. During the first week in November inflammation and 
swelling of the left leg began. This quickly passed into purulent 
infiltration of the whole of the left thigh, an opening in which 
on November 28 discharged two pints of pus in twenty-four 
hours, and smaller quantities daily for several successive weeks. 
On December 12, there was a large abscess in the axilla, which 
was lanced and discharged several ounces. Her state of debility 
was such that she could not in the least, help to feed herself. Yet 
all this time her stomach was in a state that a glutton would look 
up to as a seventh heaven. She was literally always hungry. 
As she swallowed her last bit of beef-steak she would feebly ask 
when she was to have some more, and what would be her next 
meal ; and the way her eager eyes followed any article of food 
that passed her bed was quite affecting. We allowed her wolfish 
appetite its full liberty, and fed the puny maid like a gigantic 
gladiator. The end of the tale is, that she recovered from an 
amount of purulent disease which it would have seemed impos- 
sible for the human frame to bear — and recovered perfectly, for 
I saw her in the April of the next year, looking as healthy and 
walking as briskly as if she had never been ill. 

The moral of these cases is to do all you can to increase the 
appetite, and strengthen the digestive powers. Reckon the value 



( TYPH-FEVER. 117 

of this drug and that drug, one tonic and another tonic, solely 
by the effect they have on the desire for food. If any remedy 
lessen this desire, insist upon leaving it off, whatever authorities 
may have recommended it ; and form your judgment, not from 
tradition or prescription, but from its effect in the particular case 
before you. 



LECTURE VII* 
TYPH-FEVER. 

Thekapeutical Statistics. 
{Clinical, St. Marys, October 17, 1863.) 

I have often spoken with confidence of the advantage of the 
treatment you see me pursue in fever, and I am going to-day to 
lay before you the reasons why this confidence has been growing 
yearly stronger and stronger. 

Since the opening of the hospital in the summer of 1851, to the 
time of my leaving London for the vacation last August, there 
have been registered as under my care 230 examples of continued 
fever. Of these, 109 have been treated on what may be termed 
"general principles;" that is to say, they took neutral salines 
three or four times a day, with small doses once or twice a day 
of hydrargyrum cum creta at first, and later in the disease, bark, 
ammonia, ether, and wine, when these remedies seemed required 
by the symptoms. Leeches and cupping were employed to the 
exterior of inflamed viscera as occasion called, and food was ad- 
ministered at the ordinary four daily meal-times. The other 121 
have been treated on an uniform plan of . continuous nutrition; 
animal food, in a liquid form, has been given every two hours, 
day and night, while the patients were awake, and between every 
dose of nutriment a dose of hydrochloric acid. They have been 
sponged two or three times daily with tepid water, when the skin 
was hot and dry ; and, in a few instances, leeches or cupping 
have been used to the exterior of inflamed localities in the abdo- 
men or chest. 

* The substance of this lecture was brought before the Medico- Chirurgical 
Society in April, but a few additional cases have altered the figures a little. 



TYPH-FEVER. 119 

These two classes of patients offer a fair basis for a statistical 
comparison of the therapeutical agencies brought into play : it is 
fair for the following reasons : 

1. In the first place, each series is very nearly continuous ; all 
the first-named 109 (with five purely accidental exceptions*), 
occurred in the six years before September, 1857, and all the 
latter 121 in the six years since. No fallacy can, therefore, 
arise from a selection for special treatment having been made 
intentionally or unintentionally. 

2. They are spread over a considerable number of years ; 
thus both sets include sporadic cases, as well as the produce of 
epidemics. 

3. They were all treated by the same physician in the same 
wards of a general hospital (where the cases are usually more 
severe than in special fever hospitals), and they nearly all come 
from the same group of districts of which our hospital is the 
center. 

4. The diagnoses have been made and the records kept by 
registrars who have nothing to do with the treatment, and are 
independent of the physician in attendance. 

The only opening for error that I can discern is the bare pos- 
sibility of a change of type in fevers having taken place at the 
very time when I changed the treatment, and of its having lasted 
for six years — possibilities which the records of other metropoli- 
tan hospitals during the same period reduce to nothing. 

That the severity of the disease in the two classes differed but 
little may be shown by the near equality of the periods of con- 
valescence. The mean time of stay in the hospital of the sick 
who recovered was, in the first series, 29-2 days ; in the second, 
26*7 days; being, a difference of but 2J days. The ages, also, 
of the two series differed but little, the mean age of each being 
between 22 and 23 years. 

* Three of these exceptions were treated on general principles by a colleague 
taking my duty during my absence, and unaware of the experiment I was trying ; 
in one case I made a wrong diagnosis, having mistaken typh-fever for acute 
hydrocephalus, and treated it with iodide of potassium till too late; uf the fifth 
I have no record, the patient having died within two days, and the clerk's notes 
being imperfect, except as to the fact of its being a case of fever. 



120 TYPH-FEVER. 

These averages are cited merely to show the general similarity 

of the two series, and not to demonstrate any pathological fact. 

Of the first series (viz., those treated on general principles), 

9 are entered as Typhus, and of these there died 4 

44 " Typhoid " " 16 

56 " Of doubtful or unrecorded type 3 

Total 109 Total 23 

Of the second series : 

25 are entered as Typhus, and of these there died 
52 " Typhoid " "' 2 

44 " Of doubtful or unrecorded type 2 

Total 121 4 

For purposes of comparison in a therapeutical inquiry, it will 
probably be considered right to exclude from the first table tw T o 
deaths, and from the second table one death, which occurred 
within two days of admission ; for the exhaustion caused by the 
journey to the hospital in severe fevers allows but little scope for 
judging of the action of treatment during that period. This 
leaves the average mortality under general treatment 21 in 107 
=19J per cent., or nearly 1 in 5 ;* under the second method of 
treatment, by continuous nutriment and hydrochloric acid, 3 in 

121 — 2J per cent., or only 1 in 40. 

I cannot, therefore, avoid the conclusion that the means em- 
ployed in the cases on the second list are very efficient in pre- 
serving life ; and that out of every 100 persons attacked by con- 
tinued fever, from 16 to 17 more may be saved thus than by 
treating them on general principles. 

The continuous liquid nutriment given every two hours con- 
sisted of strong beef-tea and milk, of which together about six 
pints were administered in the twenty-four hours. The hydro- 
chloric acid was given every two hours in doses of twenty minims 
of the Pharmacopoeal dilute acid in water or eau sucree. Both 
food and drugs were seen by the nurses to be swallowed, and not 

* This mortality is higher than is usual at special fever hospitals, being about 
the same as at the other general hospitals in London. 



TYPH-FEVER. 121 

left to. the discretion of patients, who, from nausea and occasional 
delirium, cannot be trusted to help themselves. 

The most immediate result of the hydrochloric acid is the 
more natural condition of the digestive mucous membrane, as 
shown at its two extremities, by the cleaning of the tongue at 
the one end and the cessation of diarrhoea at the other. The 
more natural condition of the mucous membrane enables the 
greatest possible quantity of nutriment to be absorbed to take 
the place of the tissues poisoned and interstitially destroyed by 
the virus which is the cause of the fever. That the acid in any 
chemical way neutralizes, counteracts, or evacuates the virus is, 
I think, unlikely. For the mean period of convalescence in these 
cases was shortened by only 2J days ; and certainly it would 
have been shortened more than that were the virus removed or 
rendered inert. That the convalescence is not more shortened, 
cannot of course be judged of in individual cases, and I state the 
fact from the statistics of the average stay of the patients in 
hospital, which I before quoted. 

Whether the hydrochloric acid would be equally useful in all 
climates, I cannot say ; but in Shanghai, a climate as different 
as possible from England, Dr. Henderson* states that its employ- 
ment diminished the mortality of continued fever from 28 per 
cent, to 7 per cent., a very marked decrease. 

The action of wine and of emetics in continued fevers is not 
attempted to be tested in this inquiry. In both classes of cases 
they were given ; the wine, as usual, in accordance with the 
patient's age and the condition of the nervous system, and emetics 
whenever the history we could elicit made us conjecture that the- 
fever was in its first week. My impression is that a vomit, when 
given within the first four days, materially lessened the severity 
of the fever; and in some instances seemed to cut it short, 
But I do not know how to obtain numerical evidence on the sub- 
ject. I have never found an emetic do harm, unless there were 
antimony in it, when it sometimes caused or increased diarrhoea, 
and failed of the intended purpose. For this reason I prefer plain 
ipecacuanha. 

* "Medical Times," March 21, 1863. 



LECTURE VIII. 

TYPH-FEVEK. 

Cases with running commentary — Relapse of rose-spots — Con- 
tagion from patients to a nurse — Leeches and mercury — 
Mulberry -rash — Intermittent pulse — Rose-spots or mulberry- 
spots, which most dangerous ? — Wine in fevers — Retarded 
emaciation — Subcuticular eruption — Contagion — Artificial 
cuticle in bed-sores — Sudamina — Low condition in conva- 
lescence, its symptoms. 

[It may be remarked that the date attached to the ensuing matter is earlier by 
more than five years than that which precedes it here. The cases are taken 
from the latter half of a clinical lecture published in the " Lancet " of February 
6, 1858, where, after nine others in which general treatment was employed, are 
detailed the particulars of the first twelve instances of the use of the method 
described a few pages back. It was not therefore necessary again to allude to 
these patients, nor to the fact of their having passed favorably through the 
attack. But some of them illustrating points of pathological interest, and some 
of them, besides the common treatment of the disease, having required that which 
was specially suited to each case, they are here reproduced.] 

{Clinical, St. Mary's, January 20, 1858.) 

Case 10.— William W. (Case Book 103, p. 52.) This was 
the deputy coachman from the infected house I spoke of in 
Case 8. He had equal muscular prostration but not nearly so 
much mental affection as the housemaid. On the skin there were 
rosy spots, coming out slowly and in consecutive crops. One 
peculiarity in this case is, that during convalescence, when walk- 
ing about and eating meat, he had a relapse, and the rosy spots 






TYPH-FEVER. 123 

came out again, with delirium, prostration, &c, nearly as bad as 
at first. It is very rare "to have a relapse of rosy petechia, but 
you see it is not impossible. 

Case 11.— Mary Ann B. (C. B. 103, p. 64.) A nurse in the 
hospital, had mild delirious fever without any eruption. I am 
afraid we must allow that she caught it from the patients, for 
certainly there is no bad drainage here to generate it. There 
occurs one case now and then, to show you that low fever is 
contagions, and but one to show you that it is very slightly so. 

Case 12.— Fanny A. (C. B. 103, p. 66.) This girl complained 
a good deal of pain in the right iliac fossa several times recur- 
ring, which at last was treated with leeches and mercury with 
immediate relief. You may often hesitate about these remedies, 
for fear of lowering the patient's strength by depletion ; but if 
the pain is made a subject of complaint, you may feel safe; for 
the very fact of the sensitiveness of the body shows that it is not 
too low to bear them. Those who are so much prostrated as to 
make a few leeches dangerous, are insensible to slight pain, and 
do not complain unless pressed. 

Case 13. — Emma B. (C. B. 103, p. 82.) I never saw a skin 
more thickly covered with a mulberry-rash than in this fine 
stout brunette of eighteen ; yet few have recovered so quickly. 
She came in on October 5, having been ill eight days, with a 
pulse of 120 and great prostration; on the 6th, her pulse was 
"80, and intermittent;" on the 7th, "70, and intermittent;" 
on the 8th, "natural ;" after which medicines were left off, as she 
was convalescent. I am inclined to think that the natural tend- 
ency to develop coloring matter exhibited in the skin of dark 
persons causes them also to develop more .freely than others the 
colored eruptions. 

You will read in many old books (and sound books too) state- 
ments to the effect that dark livid spots in fevers are an evidence 
of more danger than rosy spots, and that the danger is greatest 
when this dark rash is most abundant. You will have ample 
opportunities during your student life of seeing that neither of 
these rules is applicable to facts as they come before you. There 
are most deaths among the rose-spotted, and you will see many 



124 TYPH-FEVER. 

cases of unusually rapid recovery among those with a very 
copious eruption. Yet for all that I believe the ancients reported 
right. I believe that the difference is made by our more rational 
mode of treating our patients — successful in both sorts of cases, 
but most especially in those where the livid rash shows the chief 
force of the poison to have fallen on the blood. Without wine, 
the most fatal cases would be among the livid-spotted ; with 
wine, the most are among the rosy.* 

Emaciation did not commence in this patient till she w^s so 
far convalescent as to be up and dressed, and then with great 
rapidity she lost flesh. From the way in which she withstood 
and passed through the disease at its height, you would not 
have supposed her to have been so severely ill as she really 
was. But the quick destruction of all the tissues, and their 
necessary renewal before the full functions of life can be per- 
formed, show how profoundly the typhous poison affects them. 
Emaciation may be rather called part of the cure than part 
of the disease; it is nature's mode of getting rid of injured tissue. 
Case 14.— William W. (0. B. 103, p. 112.) Pink spots; 
abdominal pain relieved by leeches ; quite en regie. 

Case 15.— Edward P. (C. B. 103, p. 114.) This robust man 
was again one of a set where the fever was traceable to a poison- 
ous locality. You may remember that he made so much noise 
by yelling "Dust-ho!" that he was obliged to be removed to the 
noisy ward. He turned out to be a workman at a neighboring 
dust-contractor's, and the foreman of the yard was brought in a 
few days afterward, in Dr. Alderson's week; and a third dust- 
man came from close by, and will appear as Case 19. All these 
were very muscular men and very noisy. The first and. second 
had rosy raised spots, which were peculiarly distinct and charac- 
teristic in Dr. Alderson's patient; but the third had a livid rash; 

* Let me not be supposed to say that the use of wine in fever is a modern 
discovery. All good authorities of all ages allow it in exceptional cases ; but 
till the present generation modes of diagnosis have not been accurate enough 
to separate entirely idiopathic fever and acute inflammations ; and therefore an 
adherence to Galen's condemnation of wine was really prudent in them as a 
rule. 



TYPH-FEVER. 125 

and in the first, who is at present under review, there were livid 
mixed with rose spots. 

Remark the nature of this man's occupation. Typhous 
miasmata are perhaps generated more rapidly when the sub- 
stances whence they arise are wet, because moisture aids de- 
composition. But when once they are produced, there is much 
greater danger of their diffusion in poisonous amount from dry 
matters. Workers in sewers sometimes get poisoned by sulphu- 
retted hydrogen, but they do not catch fever : nor do the men 
who cart night-soil into the country for manure. But when this 
is spread out on the fields, and exposed to the sun and air, it' 
often causes a limited epidemic. So too, when drains are dried 
up by the summer heat, the disease is more rife than in seasons 
when they are full. A dried marsh, and the banks of tidal rivers 
exposed at low water, are made more pestiferous. So you see 
sanitary improvements require judgment as well as zeal. I be- 
lieve the safest mode of treating dust would be to wet it. 

You will observe that hearty people, when they do get low 
fever, generally have it very badly, as was the case here. I 
suppose their system is able4o resist small doses of the poison, 
and when it absorbs large doses they are the more completely 
prostrated. Be careful not to give a favorable prognosis because 
your patient is a strong man : the muscular and the corpulent are 
of all the population those who run most risk. 

Case 16.— Caroline H. (C. B. 103, p. 214.) This woman 
had great pain on pressing the abdomen, and fever stools. So 
she ought, by rule, to have exhibited a rosy rash ; but, instead 
of that, there was a dusky subcuticular eruption, which is gen- 
erally held to be of the mulberry sort. Van Swieten describes it 
as "lying very deep under the skin, as if nature, overpowered 
by the violence of the disease, could not complete the critical 
translation which she had begun."* He considers it a danger- 
ous sign, and I think he is right, as a general rule ; for, though 
this woman recovered, she was very ill. 

Case 17.— Charles N. (C. B. 103, p. 228.) This boy, again, 

* " Commentaries on Boerhaave," vol. vi, sect. 723. 



126 TYPH-FEVEK. 

had livid spots accompanying abdominal complications, which 
were relieved by leeches. 

Case 18.— Mary D. (C. B. 103, p. 228.) A washerwoman, 
who became affected immediately after receiving the dirty linen 
from a house where there had been fever patients. It seems to 
me difficult to avoid a conclusion, that low fever may become 
contagious when the poison is concentrated. It is certainly wise 
to act upon this opinion. 

Here again I made you remark the intermittence of the jmlse 
from debility during fever ; and I also called your attention to 
the natural appearance of the stools during the height of the 
disease, and to their becoming liquid and fetid as the febrile 
symptoms declined and she began to emaciate. A diarrhoea of 
such a sort at such a time is a very favorable occurrence ; it is 
a critical discharge of the peccant humors. 

Case 19.— John G. (C. B. 103, p. 232.) This was the third 
dustman. His pulse was also intermittent, as in the three former 
cases, but not till he was getting better. At first it was not 
above 80, though he was very noisily delirious, and had a brown 
tongue. You may observe this abnormal slowness of fever pulses 
to be .particularly prevalent in certain seasons. They have been 
slower than is quite consistent with the severity of other symp- 
toms this winter. 

Case 20.— Stephen F. (C. B. 103, p. 246.) I hear from Mr. 
Sanders, of Chigwell, who attends this boy's family, that they 
had fever with "mulberry-rash" in the house, and that a 
brother had died of it. Stephen was sent to London to be out 
of the way, but sickened on the day of his arrival, and had rose 
spots in several crops. It is difficult to imagine the probability 
of two brothers contracting different miasmatic diseases in the 
same house, at the same time, and from the same cause ; and the 
rational conclusion would seem to be, that both were of the same 
nature. It could only be the most overwhelming evidence which 
should lead us to think otherwise. 

Stephen was near following his brother to the grave. The 
more propitious hygienic circumstances under which he was 
placed, in an airy hospital, instead of an ill-drained cottage, 



TYPH-EEVER. 127 

weighted the scale in his favor. I do not see anything fresh to 
remark in the pathology of this case, except that the patient got 
a superficial sore on the back by obstinately saturating his sheets 
with urine and faeces, and continuously rubbing the sacrum 
against them. You must distinguish these superficial sores from 
sloughs, because the same treatment will not prevent them. 
They will be produced by friction in spite of a water pillow and 
all possible cleanliness, as in this lad's case. The best way of 
managing them is to paint the parts directly they get red with 
gutta percha softened in chloroform, of the consistence of paint, 
so as to dry immediately on application. You thus obtain an 
artificial new cuticle, and can renew it as many times a day as 
you like. 

Case 21.— Henry G. (C. B. 103, p. 292.) Instead of colored 
petechia, the eruption in this very low case consisted of miliary 
vesicles scattered like fine seeds all over the chest and abdomen. 
They are called in the case-book "sudamina." The word is 
derived from their often accompanying excessive perspiration ;* 
but remark that the association is not a necessary one; this man's 
skin was quite dry till he became convalescent. 

Case 22.f— John B. (C. B. 103, p. 106.) I have taken him 
out of chronological order, because he was not treated by mu- 
riatic acid. In fact, the fever had passed away, and he might 
be called convalescent ; yet you saw him very ill, unable to raise 
himself in bed, and with a brown crust in the center of his 
tongue. On inquiry I found that this low condition, remaining 
after the special symptoms of the fever had passed away, arose 
from inanition. Beef-tea, wine, and bark set him up directly. 
You will see a good many such cases in dispensary practice ; 
they die, though convalescent, from sheer starvation. It is of 
some importance to recognize this fact, and you will find the 
most pathognomonic sign is the coincidence of the brown tongue 
with a perfectly clear mind and cool skin. These latter show 
that the typh poison has passed away, and that the condition of 
the mouth is the result of want of nutriment. 

* Or perhaps from their likeness to beads of sweat scattered over the skin. 
f The numbers refer to the cases as they stood in the lecture originally pub- 
vshed in the " Lancet" newspaper. 



LECTURE IX. 
TYPH-FEVEK. 

Part I. — Three fatal cases since October, 1861 — One brought in 
moribund, one treated with hydrochloric acid, 8fc, one not 
— Four cases in hospital related, with comments — Banger 
of giving solid food too early in convalescence — Absence of 
enteric symptoms best guide to administration of solids — 
Dose of hydrochloric acid for children — Connection of typh- 
fever and pneumonia — Smallpox caught during convalescence 
from typh-fever. 

Part II. — Additional case, illustrative of the connection between 
the two forms of typh-fever eruptions — Precautions in case 
of threatened pneumonia — Caution against moving patients 
in fevers. 

Part III. — Four additional cases with comments. Case. 1. — 
Difficulty of distinguishing typhus and enteric fever — Relief 
of enteric pain — Dry, glazed, cr ached tongue in enteric cases 
— Arrest of diarrhoea by hydrochloric acid, by Dover's 
powder, Sj-c. Case 2.— Fever spots and flea-bites — Fever 
cut short by an emetic — Emaciation during convalescence 
not prevented by the cutting shoi't of the fever. Case 3. — 
Fever cut short by an emetic — When not arrestive, this 
treatment is palliative. Case. 4. — Fever contracted in the 
hospital aggravated nearly to a fatal extent by inflammation 
of previously diseased genital organs and bladder, and by a 
slough on the sacrum — Treatment. 

Part IV. — Case of typh-fever contracted in the hospital by a 
patient admitted for acute rheumatism — Emetic only par- 
tially successful — Administration of solid food and wine. 

(Clinical, St. Mary's, January 10, 1863.) 

Since October, 1861, when I last discoursed to you on con- 
tinued fever, it has been more than usually prevalent in both 



TYPH-FEVEK. 129 

its enteric and typhus forms, especially in the latter form during 
the present session. I have persisted in the employment of the 
same treatment I then commended to your notice, and with the 
same encouragement to proceed. 

There have been two deaths among those so treated. One 
was in the case of a little boy, age unknown, who was carried 
into the ward December 17, 1861, quite unconscious, cold, 
pulseless, with livid lips and colliquative diarrhoea. I scarcely 
can tell how much of the nourishment given him was swal- 
lowed, and he did not survive the morrow of his entering the 
hospital. 

I should have liked to know in what state this child was 
before he was brought away from home. It is not at all im- 
possible that he might then have been in a condition admitting 
of recovery ; for children very rarely die of typh-fever, however 
severely they may have it. At all events, it is certain that the 
exhaustion of the journey hither was the immediate cause of the 
fatal result. The patient was, to all practical purposes of 
restoration, dead before he came inside the doors. 

If your future pursuits should place under your charge poor 
people at their own houses, I do hope that events such as these 
(and they are sadly common) will make an impression upon you. 
Pray do not send bad cases of typh-fever out of their beds to be 
dragged in an exhausted state to a hospital. None of the ad- 
vantages to be obtained there can compensate for the chances 
of life so thrown away. 

Another death occurred in a girl of eighteen. I was away 
for my holiday at the time of her decease, and no post-mortem 
examination of the body was permitted by her friends ; nor are 
the clerk's notes very explicit — they seldom are in vacation 
time — but as far as I can judge from the history given me by 
the ward-sister, she seems to have yielded to a very rapidly 
congestive pneumonia. I am very sorry to have no further 
information about her, as nothing is so instructive as the 
investigation of the causes of failure of treatment usually suc- 
cessful. 

Another case of death from the inflamed and ulcerated bowels 



130 TYPH-FEVER. 

which so often accompany typh-fever, occurred in November 
last. But she was unfortunately not treated in my usual way, 
for a reason which I will take the opportunity of telling you as 
a warning, as I trust the same reason is likely to be rare. The 
patient, Elizabeth T — , was a girl of eleven years old, who was 
brought here October 24, with intense headache, deafness, 
delirium, vomiting, picking at the nose, and other symptoms, 
which the mother attributed to a blow on the back of the head. 
This led to a wrong diagnosis, and the child was, by my orders ? 
treated with iodide of potassium, and blisters on the vertex, as 
for inflammation of the brain (hydrocephalus acutus). I was 
absent from London at the time of her death also, but a post- 
mortem examination was made. The brain was congested and 
wet, as it usually is in those that succumb to acute fevers, and 
have blood more fluid than natural. There was however nothing 
like the appearances caused by acute hydrocephalus, nor any 
trace of injury. On opening the abdomen, the cause of death 
was at once referred to the ilia, which were extensively inflamed 
and ulcerated in the manner usual in typh-fever. 

I wish people would more frequently put on record mistakes 
made in diagnosis ; they are full of interest and instruction for 
themselves and others. 

The rest of the fever patients which have passed through the 
wards have done well, and I have no record of anything note- 
worthy in their cases, beyond circumstances to which I have 
called your attention in former lectures apropos of former 
instances. I do not lecture to you about by-gone patients, 
except they have presented phenomena unlikely to occur again, 
preferring to wait patiently till I can illustrate my words from 
the life. 

I will confine my remarks, then, to the four cases now remain- 
ing under your, eyes, two in the male, and two in the female 
wards. 

Elizabeth T— , aged twenty-two, was made my patient Decem- 
ber 9, 1862, with rose-spotted fever of five days' duration since 
the introductory rigor, with very thickly coated tongue, diarrhoea, 
and severe pain on pressure of the abdomen. Everything went 



TYPH-FEVER. 131 

on well, no fresh spots came out after the 13th. On the 18th 
the appetite returned, and she was allowed fish diet at her 
urgent request, although some tenderness remained in the abdo- 
men, and on the 20th meat and beer. On the 25th it seems her 
appetite had failed again, and she had a rigor and some vomit- 
ing. When I saw her on the 26th she was unable to stand ; 
her whole aspect denoted a relapse, and I sent her to bed with 
a return to mj usual treatment of fever, dietetic and medicinal. 
It was a short attack, and no spots were seen on the skin. So 
that on January the 7th, she was convalescent, and is now eating 
solid meat. 

The remark I have to make on this case is to warn you 
against too early yielding to the request of patients for solid 
food. They have a fallacious notion that it is more nutritious 
than the continuous liquid diet which is given them, and in order 
to get it will pretend to feel more appetite than they really do 
feel. They will also often conceal that tenderness of the abdo- 
men which is the sign of the yet unhealed congestion of the 
mucous membrane of the ilia. I should tell you, too, that when 
the patients take hydrochloric acid, you are more frequently 
tempted to the error in judgment against which I am warning 
you than when they have other medicines. The acid causes a 
more rapid renewal of the lingual, and I suppose, at the same 
time, of the intestinal, epithelium : the dead, dirty coat is cleared 
away, and you have a clean tongue earlier than would otherwise 
happen. I was talked over by the patient too easily in this case, 
and ought to have been deterred, by the abdominal tenderness, 
from giving her meat so soon. The consequence was, the slight 
relapse which you have witnessed. 

William W — , a dirty, dissipated-looking person, thirty-six 
years of age, was sent to bed on the 28th ult., in a state of weak- 
ness and constant delirium, which entirely prevented his giving 
any account of himself; and now that he is getting well, his 
memory of recent events seems very dim. He was said however 
to have been ill a week, his body was covered with livid spots, 
his tongue was brown and dry, and his tremulous hands kept 
picking at fancied objects before his eyes and on the bedclothes. 
There was no diarrhoea or pain in the abdomen. 



182 TYPH-FEVER. 

He was treated in the usual way, and had ten ounces of port 
wine daily, with the usual result. 

It is noted in the diary that he had some evacuation of liquid 
motions soon after admission, but that the stool was " natural" 
in appearance. What is meant is that it was such as is 
naturally caused by a purgative drug, not the dark fetid excre- 
tion of fever, and in fact was traceable to an emetic draught 
which was administered on admission, and which did not cause 
vomiting and therefore went off by the bowels. Be careful to 
distinguish phenomena arising in the course of disease which 
are caused by art from those which are morbid and part of its 
essence. 

This man had no real diarrhoea and no pain on pressure of 
the abdomen, and therefore I did hot hesitate on January 7 
to order him meat diet on his expressing himself desirous of it, 
although he was not sufficiently recovered of his fever to be able 
to raise himself in bed ; and I feel confident he will continue, as 
heretofore, to do justice to his treatment. 

Edward C — , a boy seven years of age, was seized on De- 
cember 28 with rigors, nausea, loss of appetite, nocturnal 
delirium, and febrile depression, so that he could not lift up his 
head. He was brought under my care on December 31, by 
which time there were numerous dusky fever spots on the belly. 
He was put upon the usual treatment, and is now convalescent. 
I have to remark about the orders on the medicine card, that he 
took the same quantity of hydrochloric acid which is adminis- 
tered to adults, namely, twenty minims every two hours, without 
any inconvenience following. I have not generally given such 
large doses to children, but shall know now that it may be clone 
with propriety. 

It is remarkable that a few days before this boy was attacked 
by typh-fever, without any local complication whatever, his father 
fell ill, and was brought into the hospital on December 29, 
with pneumonia affecting between one-third and half of the left 
lung. The father has had no delirium, nor more nervous de- 
pression than is accounted for by the condensation of the lung, 
no eruption on the skin, no diarrhoea, nor anything which would 



TYPH-FEVER. 133 

lead one to set down his complaint as due to the same cause as 
his son's. Yet the coincidence, joined to the fact of their resi- 
dence being in an ill-drained, ill-ventilated house, where almost 
every one has been ill, is too striking to be passed over in 
silence. Did the exposure to cold and wet during his daily 
labor predispose the hard-worked father's lung to be affected 
by the same cause, the typh-poison, as absorbed into the boy's 
blood acted principally on the nervous system ? Was his more 
robust frame, and the dura messorum ilia able to pass unscathed 
a dose of the typh sufficient to poison the more delicate tissues 
of the younger subject, while at the same .time his lung, devi- 
talized by wearing toil and exposure, yielded to its influence ? 
Is, in short, the pneumonia the expression of a quantity of poison 
enough to injure a failing part but not enough to affect his 
whole body ? I do not like to answer these questions ex 
cathedra, but I cannot help seeing some connection between 
typh-fever and inflammation of the lung. 

The different way in which the same morbid agent affects 
different individuals should guard you against considering it as 
the disease, against looking upon illness as something to be 
evacuated or neutralized. The disease, that against which you 
have to struggle, is the partial deficiency of life caused by this 
morbid agent, and your struggles must take different forms 
according to the different forms of the deficiency. 

The fourth case of typh-fever still in the hospital is that of 
Sarah H — . She is a married woman, aged twenty-eight, of 
slim figure, and not muscularly strong. She was admitted De- 
cember 5, having rose-spotted fever of three days' duration 
since the rigor, and accompanied by delirium. As is usually 
the case with delicately-framed susceptible females, the nervous 
system was especially affected : w r e were forced, in addition to 
the usual fever treatment, to give her a great deal of port wine ; 
the belly became tympanitic, and I was at one time seriously 
alarmed about her. However, on December 18, she was in her 
right mind and convalescent, though unable to raise herself from 
the lying posture for her natural evacuations. 

I mention the fact of her being quite confined to bed for a 



1 34 TYPH-FEVER. 

special reason. On the last-named date there was in the ward 
for a few hours, a patient who was discovered to have variola, 
and was sent off to the Smallpox Hospital. Now, Sarah H — 
was the only unvaceinated person in the ward, and the conse- 
quence was that she received the infection, and has since gone 
through a severe attack of the confluent form of smallpox. In 
spite, however, of having thus imbibed a new poison, she con- 
tinued to increase in health and strength till the 30th. On the 
morning of the 31st she had a decided rigor, she became feverish, 
lost her appetite, and had nausea. The pulse rose to 110. 
Thinking she was about to have a relapse, like the first patient 
to whom I drew your attention, I put her back on the usual 
fever treatment, which she has continued to have ever since. 

One piece of information you may gain from the accident of 
this unfortunate patient having the two diseases so close upon 
one another, is the fact that typh-fever does not prevent a person 
receiving the infection of smallpox. A second is, that the pres- 
ence, in a latent state, of the morbid poison which gives rise to 
the latter disease, does not retard the progress of convalescence 
from the former ; and is in reality dormant as well as latent. A 
third is, that on the whole, the sufferings from smallpox are 
more severe than those from typh-fever. Our patient declared, 
at first, that the fever was the worst of the two, but by the time 
the pustules had completely maturated, and she was sore all over, 
she frankly confessed to me her error. 

[Clinical, St. Marys, February 13, 1863.) 

On Ellen D — , a servant-girl aged sixteen, who came under 
your observation three days ago with typh-fever of a week's 
duration, you have seen an instance of two of the most common 
forms of eruption in this disease. The bosom and abdomen were 
thickly covered with dark livid spots, many of them as deep 
purple as those of purpura hemorrhagica. She was in a very 
low state, the blood being very venous. Yesterday, in addition 
to the purple spots, I observed on the abdomen several spots 
slightly raised above the surface of the skin, and of a much more 



TYPH-FEVER. 135 

pinkish hue. Her hair, and probably therefore her skin, are 
naturally dark, so the maculae are not so pink as they would be 
in a blonde complexion ; but still, no one would hesitate to call 
them " typhoid" spots. This shows you the great difficulty that 
lies in the question of whether there are two distinct animal 
poisons causing " typhoid" and " typhus" fever. Doubtless, it 
is not impossible that both may exist in the body at the same 
time, and give rise to two distinct fevers at the same time ; just 
as a person might be poisoned by a mixture of strychnine and 
antimony, and exhibit the effects of both drugs together. But 
in the case of morbid poisons which increase in the body, such a 
joint progress shows at least a very close relation between the 
two. There are also other instances where the eruption seems 
to exhibit a transitional character, or where there is not a suf- 
ficiently distinctive eruption. In our register these cases are 
not distinguished, but are entered simply as " fever." If then 
there' are two poisons which cause typh-fever, a point I consider 
not proved, they must be much nearer allied to one another than 
those which originate the usual eruptive fevers, such as scarlatina, 
smallpox, &c. 

You may have observed that I am loose in my nomenclature 
of this class of diseases, speaking sometimes of " common con- 
tinued fever," sometimes of "continued fever," sometimes of 
"low fever," sometimes of "typh-fever," sometimes of "fever" 
simply, when I mean the same thing. This is not from careless- 
ness, but to show you my opinion that for therapeutics, to which 
the greater part of my clinical lectures refer, the name is unim- 
portant ; and also because the terms "typhoid" and "typhus," 
having acquired a special limited meaning, and when used by 
me, being used in that special limited meaning, are unsuited to 
my general purpose. Their employment would seem to prejudge 
a question upon which I am not engaged in this chair. 

I should advise you also not dogmatically to prejudge the 
question. Use, if you like, the popular nomenclature, but do 
not be skeptical of the possibility of the eruptions being phe- 
nomena of one morbid poison, varied by varying circumstances, 
any more than you are skeptical about their being indications of 
two poisons. 



136 TYPH-FEVER. 

There is no necessity for being in a hurry to decide, for it is 
not a matter of any importance to yourself or your patient. 
Both forms of disease are infectious to a certain extent, as occa- 
sional instances in the wards show you. Typhus is said to be 
most so, perhaps from its following a larger dose of the poison ; 
but neither are very infectious, and do not require the extraor- 
dinary precautions proper for smallpox, measles, or scarlatina. 
And both call for the same treatment, and are accompanied, 
though in varying proportions, by the same local inflammations. 

While on the subject of typh eruptions, I may take the oppor- 
tunity of warning you not to limit your observations solely to 
the surface of the chest or abdomen, as is very commonly done. 
The flanks and buttocks are often the seat of them, and I have 
sometimes found spots very marked and indubitable in these 
situations, when their presence elsewhere was doubtful. In 
females especially it is convenient to find them here, as it obvi- 
ates the necessity for baring the front of the person, a proceeding 
naturally repugnant to a delicate mind. 

In this girl there was great general congestion of the lungs ; 
the respirations were much hurried, amounting to thirty in the 
minute ; there were sibilant rales all over the chest, most intense 
at the back part ; but there was no localized dullness on percus- 
sion. In consequence, I believe, of this congestion, the pulse 
was quicker than usual, 140 in the minute ; for you will rarely 
find it above 120 when the pulmonary tissue is in a healthy 
state. 

When there is such an amount of congestion as to produce 
marked dyspnoea, it is better to omit the usual sponging of the 
surface of the body, or you run the risk of pneumonia. This 
had been done in the present instance, and the chest has been 
enveloped in a "jacket poultice." She now breathes easier, has 
less cough, and the pulse has sunk to 110, getting stronger at 
the same time. The continuous and even temperature 'of a 
poultice is by far the best means of restoring the deficient vitality 
of the lungs, where that deficient vitality is general, instead of 
being localized in one spot, as it is in circumscribed pneumonia. 

You may observe that almost all non-delirious patients with 



TYPH-FEVER. 137 

tjph-fever say, on the first visit, that they are worse than before 
they left home to come into the hospital. Sometimes even 
deaths occur within the first thirty-six hours, of which I related 
you an instance in a former lecture,* the patients being, in fact, 
death-struck from the moment of admission. This arises from 
the exhaustion induced by the journey hither, of which you may 
always see traces, however short it may be. Removal even from 
the next street does harm, and the harm increases in a mathe- 
matical ratio to the time and distance required. Bringing 
patients in from a great way is most murderous ; no excellence 
of nursing or superior comforts can atone for the risk run. As 
far as we possibly can, we limit our reception of typh-fever to the 
neighboring parishes, and prevent persons from a distance being 
admitted, if we hear beforehand of their coming. And once 
within the walls, they are spared every unnecessary movement ; 
they are sent up stairs to bed in the lift, not allowed to raise 
their heads from the pillow to drink, and are supplied with a 
bed-pan for the other calls of nature. 

In typh-fever everything depends on sparing most avariciously 
the little vital force that remains. You will have reason to 
regret every muscular exertion that you allow patients to make. 
I was called lately to Hertford to see what seemed to have been, 
and to be, a very moderate case of fever with intestinal affection. 
None of the distinctive bad symptoms peculiar to the disease had 
showed themselves. But unfortunately the patient had been at 
Brighton when taken ill ; she pined for home, was allowed to 
move thither, and never rose from the prostration caused by the 
journey. I have heard of cases where the permission to sit up in 
a chair, instead of lying in bed, has resulted in fatal prostration. 

You will find of course more obstinacy on this point among 
the upper classes than the lower, and you will sometimes have 
great difficulty in overcoming it. But it is your duty to try and 
do so ; and should patients persist in disobeying orders to keep 
quiet, I advise you rather to cease your attendance than to give 
way. You must not allow people to sacrifice your good fame as 
well as their own lives. 

* January 10th. See page 129. 
10 



138 TYPH-FEVER. 



{Clinical, St. Mary's, March 6, 1863.) 

Eliza C — , a stout, muscular girl of eighteen, was received 
February 27, with the usual symptoms of continued fever. 
The eruption was at first of a doubtful character ; nobody could 
have decided accurately whether the spots were a pale example 
of those usually called typhus, or whether they were fading 
typhoid spots. This difficulty is one of the many which beset 
the investigation of the question of their identity or non-identity. 
Inasmuch however as from the same house her sister was at the 
time under my care, and an aunt had just died with indubitable 
typhus, I thought it very likely her eruption would exhibit the 
same variety of appearance. But no — it proved not so, for 
since then many rosy spots, slightly elevated above the surface 
of the skin, have come out in successive crops. I mention this, 
because these rosy spots are a warning to the physician that he 
may expect inflammation of the intestines. And the warning 
has been justified in this case ; for the patient's principal complaint 
during the last few days has been pain in the abdomen, aggra- 
vated by pressure of the right iliac fossa, and much lightened 
by a linseed-meal poultice. There is nothing does patients with 
enteric symptoms so much harm as moving about and the 
impression of dry cold, and nothing does them so much good as 
lying quite still on the back and applying moist warmth. A 
poultice accomplishes both objects, it keeps the patient im- 
movable, and acts as a sort of perpetual warm-bath to the 
abdomen. It entails of course abstinence from the sponging 
treatment. 

Another warning of enteric inflammation was seen in her dry 
tongue, without much coating of epithelium, and with transverse 
cracks from side to side. It is seldom that you see a tongue like 
this without the intestines being inflamed. 

This girl has had scarcely any diarrhoea. The fact is, that 
the hydrochloric acid treatment always prevents the diarrhoea of 
fever from attaining any prominence as a symptom. There is 
usually just about enough to show what it would be if not stayed. 



TYPH-FEVER. 139 

Should the hydrochloric acid alone be not sufficient, the diarrhoea 
is best treated by Dover's powder, both the opium and the 
ipecacuanha in that preparation being good for dysenteric in- 
flammation. Kino powder is also applicable to such cases ; but 
chalk is of course out of the question while you are administering 
hydrochloric acid. 

Thomas W — , a robust boy of sixteen, was brought here 
February 28, with symptoms of low continued fever of three 
days' duration. There was very great depression when the resi- 
dent medical officer, Dr. Rhodes, saw him then, and he fully 
expected it was going to be a very bad case. He ordered an 
emetic immediately, and the consequence was the vomiting of a 
quantity of blackish matter like semi-digested blood. When I 
saw the lad the next day, he was so brisk-looking in the face, 
and exhibited so little febrile depression, that at first sight I was 
disposed to question Dr. Rhodes' diagnosis. But then I was 
shown the abdomen and chest covered with small purple spots. 
Even then I was not convinced, and put the spots to the test of 
examination by the microscope. I thought they might be flea- 
bites. 

Now, fleas cannot leave their marks without a puncture, and 
in all flea-bites you may, with a lens of very moderate power, if 
not with the naked eye, detect this puncture as a very minute 
dark-crimson point. The spots stood this test, there was no 
puncture, and they were certainly purpuric typhus spots, which 
have since faded away. But how is it that he had, and, indeed 
has had since, so little febrile depression ? The fact is, this is 
one of those fortunate cases of a fever cut short by an emetic. 
He is now emaciating, and emaciating extensively, and con- 
valescent. 

In the last sentence I laid some stress on the word " emaciat- 
ing." The emaciation is a phenomenon of great interest; it 
shows how large an amount of tissue is interstitially poisoned in 
typh-fever ; how large an amount requires to be carried off by 
destructive metamorphosis during the renewal of life. In such 
cases as this, when the fever is cut short, it by no means follows 



140 TYPH-FEVER. 

that the emaciation should be cut short, and in point of fact it is 
not so. The removal of the destroyed tissue is a necessary part 
of the case. 

Strokes of good fortune are sometimes equally gregarious with 
the proverbially " seldom single" misfortunes. Next bed to the 
boy lies a man whose fever has been in the same way cut short 
by an emetic. Thomas B — , aged nineteen, exhibited on the 
3d of March the usual symptoms of continued fever of three days' 
duration. There ha,ve been all along but few spots, and those 
of obscure indeterminate character on the abdomen. But he had 
the aspect of being very ill, and his tongue was thickly coated 
with yellow fur, and showed a tendency to get dry. , He was 
treated in the same way as the last patient, with an emetic and 
hydrochloric acid, and has entered forthwith upon convalescence. 
It is now nearly two years since I have had a case of fever so 
decidedly cut short by an emetic ; so do not expect it often ; but 
nearly all have the violence of the disease alleviated by that 
remedy ; so that it is never out of place during the first week of 
the fever. 

Emily H — , aged twenty-six, married, was entered to the 
ward assigned to uterine diseases, for irritability of the bladder 
arising from antiversion of the womb, in middle of last month. 
On the 2d instant she was taken with feverishness, loss of appe- 
tite, and pains in the head and back. She had a rigor that 
night; she was transferred to me yesterday; and then there 
were obscure livid spots on the abdomen, and pain on pressure. 
She has been put on the usual treatment, and it appears likely 
to prove a mild case of typhus fever. I only mention it here as 
having been apparently contracted in the hospital, which I am 
glad to say is not a common occurrence. 

{Clinical, St. Mary's, March 20, 1863.) 

Emily H — , about whom I said a few words on the day after 
her coming under my care, has given us more anxiety than I had 
looked for. Her antiversion of the uterus had been treated by 
a pessary, and her delirious, semi-conscious state, caused by the 



TYPH-FEVER. 141 

fever, prevented her making this known to the nurse. The in- 
strument was removed immediately that it was discovered, and 
was followed by an excessively fetid discharge from the vagina, 
which lasted some days. A vaginitis had, in fact, been produced 
by the pressure, easily enough borne by a healthy vagina, but 
acting destructively on that part when its vitality was lowered 
by general disease. I was fearful that the patient was going to 
have internal sloughing, but she has escaped by good fortune 
and the use of an injection of decoction of cinchona and chlori- 
nated soda. She has escaped so far as her generative organs are 
concerned, but not altogether : the vaginitis and fever united 
entirely paralyzed the sphincters of the bladder and of the 
rectum, and it was impossible to prevent the pillow on which her 
sacrum lay from being soaked with the excretions. Her con- 
stant delirium also, at first, made her very unmanageable. We 
could not prevent the pressure on the sacrum as we did in the 
other part, and the consequence is that she has rather a deep 
slough formed there. 

This woman afforded an example of how the mental qualities, 
as well as the corporeal, suffer degradation in illness. During 
her raving she was constantly attempting to practice masturba- 
tion, and was uncurbed by shame, so that the nurse was obliged 
to be constantly on the watch to withhold her. I have no reason 
to suppose her a generally vicious person, and in recovering her 
reason she has recovered her modesty and self-restraint. When 
the human mind loses some of the divine powers bestowed by its 
Creator, it becomes as the mind of a brute. Madness is not 
something added to it, but something taken away ; those powers 
are taken away by virtue of which it is said to be made " in the 
image of God," and by virtue of which it resists degrading in- 
fluences. The degrees or forms of madness are degrees of loss 
of free-will and self-control. 

I am happy to say she has now become rational, and also re- 
gained control over her sphincters, so that she is on the road 
toward convalescence. But if any more accidents happen, I will 
bring the case before you again. 

You saw that till the inflamed, or dying, portion of skin gave 



142 TYPH-FEVER. 

way and broke, I kept it carefully painted over with gutta percha 
dissolved in chloroform ; she has also had a water-pillow. The treat- 
ment was unsuccessful indeed in this instance, but still it is the 
best. After the skin was broken, a cinchona cataplasm was ap- 
plied, which, by-the-by, I may tell you how to prepare most 
economically. Do not make it entirely of bark, but sprinkle the 
powder thickly over a common bread or linseed poultice ; you 
thus save an expensive drug, and also keep it moister. Now that 
the sloughy cellular tissue has separated and been cast off, I shall 
treat the sore by touching it alternately with nitrate of silver and 
applying tincture of benzoin, whenever the edges look livid and 
unhealthy. 

These low inflammations in continued fever are almost always 
a reason for giving alcohol to sustain the nervous system. Emily 
H — ■ had at first six ounces of port wine daily, but I was soon 
obliged to increase her allowance to half a bottle, and she will 
probably continue that during a great part of her convalescence. 
There is danger in suddenly leaving off stimulants which have 
been begun in fever. 

(Clinical, St. Mary's, January 24, 1863.) 

Elizabeth J — , aged nineteen, came in on January 16, with 
rheumatic fever, affecting principally the feet, knees, and hands. 
There was one day considerable pain on pressure of the cardiac 
region, such as is caused by rheumatism of the intercostal 
muscles ; but that was immediately relieved by the application 
of half a dozen leeches, and there were no symptoms or signs of 
the disease spreading to the heart or pericardium. The pains 
were quite gone on the 21st, and on Sunday, January 25, she 
was up and dressed, though still on the low diet, which seems 
best to suit convalescents from acute rheumatism. On that day 
she was taken with rigors, sudden loss of appetite, severe pains 
in the head, in the back and limbs, and complete prostration of 
strength. When the house surgeon saw her in the evening, the 
tongue was exceedingly clammy, and covered with a whity-brown 
coat, as if getting dry ; she was delirious ; the pulse was 120 ; 



TYPH-FEVER. 143 

and the skin hot, and of a dusky mottled color. Now, these 
symptoms were certainly not caused by the alkaline treatment 
of the rheumatic fever, for she took the bicarbonate of potash 
only five days, was not prostrated by it, and had left it off for 
four days ; but as there had been a constant succession of bad 
cases of typhus fever in the ward, and the patient had all the 
symptoms of that complaint, Dr. Rhodes wisely decided that she 
must have caught it ; and he, wisely also, acted in a decided 
manner. He immediately gave her an emetic, and put her on 
continuous liquid animal diet and hydrochloric acid every two 
hours, with tepid sponging three times a day. 

I have told you that emetics will sometimes extinguish a typh- 
fever by a kind of coup-de-main. But really the cases in which 
this fortunate result follows are so rare, that you might hesitate 
whether it was worth aiming at, if no other good was to be 
gained by such bold treatment. It did not follow to the patient 
now under consideration ; she remained delirious, quietly talking 
nonsense about various things ; during the next day (Monday) 
and part of Tuesday, her tongue got dry, although cleared by 
the treatment, and the pulse kept quick. The prostration and 
tremor of hands were very great. It was impossible not to con- 
clude that she was under the influence of a powerful poison. 
The cause of the disease was not removed, nor the disease 
extinguished. 

Yet, though not extinguished, it was certainly shortened, for 
on Wednesday you saw her with her tongue clean and moist, the 
skin much cooler, and the pulse, though still 120, much firmer. 
Now, the normal duration of such a severe typh-fever, as she 
gave every promise of having to go through, is at least three 
weeks ; and she would have had, in the course of nature, to be 
much worse before she was better. But here you see her in three 
days enter upon a convalescence which I do not doubt will be 
permanent ; and I cannot help attributing this abbreviation of 
the malady to the emetic. 

She was so much better on Wednesday, that I was asked if 
she should leave off the acid and be put upon the bark treatment 
of convalescence, and also whether she should have wine. I 



144 TYPH-FEVER. 

have never made the alteration of medicine so early in the disease 
as this ; but I have occasionally been induced by the cleanness 
of the tongue to do so only a few days later, And I must say, 
I have usually seen reason to regret it. The too early adminis- 
tration of cinchona, as well as the too early administration of solid 
food, have appeared to me to have been the causes of relapse in 
several cases. It is better not to give cinchona at all, and to 
postpone solid food till the patient is quite strong again, than 
to give them imprudently soon, and so to run the risk of re- 
lapse. 

As to wine, seeing that she is a young girl not habituated to 
alcohol,. and has got over her delirium without it, I think it a 
superfluous expense. 



LECTURE X. 
SMALLPOX. 

Part I. — Case of smallpox watched from first infection — Se- 
quence of phenomena — Memoria technica by which to re- 
member them — Use of observing them — Action of oxygen on 
the general health of the patient and on the shin contrasted — 
Microscopical examination of the contents of the pocks, with 
practical deductions therefrom — Depth of injury to skin in 
smallpox — Reasons for cutting the hair. 

Part II. — Spread of smallpox in the hospital from the above 
case— Example of the use of vaccination in modifying the 
disease — Action of vaccinia not homoeopathic or counter- 
irritant, but preventive — Infectiousness of smallpox com- 
pared with other diseases — Different degrees of infectious- 
ness demand different precautions. 

(Clinical, St. Mary's, January 16, 1863.) 

You have had an opportunity, such as rarely falls to the lot 
of medical students, of watching the whole progress of smallpox, 
from the first introduction of the poison into the body, in the 
case of a young woman about whom I lectured last week apropos 
of her previous attack of typh-fever.* On December 18, Sarah 
H — was confined to her bed in Victoria Ward, when a person 
with a variolous eruption fully developed was brought in, the law 
excluding such cases having been violated by an oversight con- 
sequent on the occupation of the officials by a hospital election. 

* See page 133. 



146 SMALLPOX. 

This person remained about two hours in the ward, and was 
never nearer to Sarah H — than thirty-six feet. But an extra 
nurse, who was then engaged, may very likely have been in 
attendance on both, and have carried the infection in her clothes, 
not having been reserved, as she ought to have been, to the 
dangerous patient. That such a mode of transfer may have taken 
place is rendered probable by this nurse having communicated 
smallpox to her own child, with whom she slept, without taking 
it herself. The nurse, however, and all in the ward except Sarah 
H — , had been fully vaccinated ; and it shows the powerful 
protection thus afforded, that all escaped personal harm except 
Sarah H — . On her, indeed, the operation had been attempted, 
but it had failed. 

Here you have been enabled to fix the exact time when the 
poison was received, and to trace the history of the resulting disease, 
unmodified by any protective or disturbing causes. The pathology 
of smallpox, as we are taught in the books of systematic medi- 
cine, is derived from such examples as these, occurring in the 
olden time before it was neutralized by Jenner's immortal dis- 
covery. And it should give us confidence in our forefathers' 
powers of observation that cases of unmodified smallpox, then 
the rule, now happily the rare exception, are rightly described. 
You have seen a sequence of phenomena punctual to the due 
times laid down by them, and which I teach you in my systematic 
lectures on their authority. Twelve days did the seed lie dormant ; 
then its presence was declared by a three days, a more properly 
two days and a half, fever (counting from the first rigor) ; then 
for two days it bore a crop of papules ; after that, a vesicle 
growing gradually opaque for three days more, and then for two 
days encircled by a halo of rosy inflammation ; the next night 
brought the evidence of the complete filling of most of the pus- 
tules, by the rupture of the little band of epidermis which had 
hitherto fastened their centers to the cutis. When the vesicles 
were two days old, the face swelled and there was considerable 
salivary secretion ; and the distention of the pustule was ac- 
companied by swelled extremities. Since then the eruption has 
been gradually drying up. 



SMALLPOX. 147 

To assist my memory as a pupil, I put these facts into some 
doggerel Latin verses : 

Bis sex celatur virus, tres febre notatur, 

Fertque duos soles papulam, tres postea opaquam 

Vesicam, roseumque duos perfeetior orbem ; 

Yincla cutis medii dissolvit postera luna. 

Bidua vultum inflat vesica, movetque salivam. 

Pustula fert distenta maniimque pedumque tumorem. 

Rough and bad as they are, they served my purpose. You 
may easily fix them in your minds by taking the trouble to make 
improvements in the versification, for which there is ample room. 
There is a real clinical use in such an exertion of school-boy 
knack. 

This normal order of the phenomena of variola is important to 
remember, not merely because it is a matter of scientific interest, 
but that you may be able to satisfy yourselves and your patients 
that all is going on right, and that the very disagreeable and 
painful appearances which they present are not signs of over- 
hanging danger. I refer especially to the swelling of the face 
and hands occurring in proper succession, and which would be 
alarming if unexpected ; whereas if you are enabled to foresee 
them, they are rather good omens than the contrary, and are a 
source of justifiable consolation. 

The unvarying sequence of the symptoms in smallpox may also 
serve in doubtful cases as a means of diagnosis, not only from 
other eruptive fevers, but even from chronic diseases. I have 
known, for instance, a case of eruption in a baby at the breast, 
where it was impossible to decide, by the appearance, whether it 
was variolous or syphilitic, and where the counting of the days 
alone enabled a conclusion, afterward proved correct, to be 
come to. I see you smile at the idea of two such different diseases 
as syphilis and smallpox being confounded. But your smile is 
one of imperfect knowledge. Syphilis, child of sin, shows its 
kinship to the father of lies by imposing upon us imitations of 
almost every innocent morbid state ; and among the rest it 
will often, in the infant, assume the exact aspect of smallpox, 
with central depression, red halo, and other usual diagnostic 
marks. The reckoning of the days of latency and of the progress 



148 SMALLPOX. 

of the eruption will alone save you from falling into our fore- 
fathers' original error of confounding the "small" and the 
11 great" pocks in babies. 

You may have observed that this woman was placed in a large 
room by herself, with a blazing fire and two windows open night 
and day. To this access of fresh air to the lungs a great part of 
her freedom from the unfavorable symptoms so often accompany- 
ing confluent smallpox is doubtless to be attributed. She has 
enjoyed her liquid food all along, and has several times prompted 
the addition of eggs, pudding, ale, &c, to her diet card, and I 
have no doubt will ask for solid meat as soon as the sore pustules 
in her throat will allow her to swallow it. 

But though the copious access of oxygen to the lungs is so 
highly desirable, I question very much whether it is equally 
desirable to the skin. I am led to this doubt by the following 
observation. When the pocks were filled out, I opened a good 
many with a lancet, and examined under a microscope the con- 
tained matter. This was divisible into three classes : 

1. That taken from pocks of small size and with slight inflam- 
matory halo. It was of the consistency of thin lard, white and 
opaque. Microscopically examined, it was seen to consist en- 
tirely of epidermic scales, the majority of normal aspect, but 
some filled with granular matter hiding from view the usual 
nucleus. 

2. That taken from distinct and non-confluent pocks, with a 
broad halo, but not the largest or most humid of their kind. 
Here the normal scales were few, the granular scales equalizing 
them in number, but more numerous than either were pus- 
globules of various sizes and of irregular shapes, as if budding 
on several sides. 

3. That taken from the worst of the distinct pocks and from 
the confluent parts. This consisted in several specimens entirely 
of equal sized pus-globules, with many dark specks and highly 
refractive fat-globules among them. There were hardly any 
epidermic scales visible! 

Three grades of death in the skin are represented by these 
three classes. In the first, the growing epidermis is merely 



SMALLPOX. 149 

loosened and thrown off in a pasty state ; in the second, the cells 
are destroyed at an earlier stage of their existence, and only 
partially acquire a right to be called scales at all ; in the third, 
they are killed still earlier, and their constituents form new pus. 

By the last condition certainly, and by the second possibly, 
the cutis runs great danger of being permanently scarred. Any 
accidental rubbing or disturbance must risk the causing it to 
ulcerate, and thus to form a pitted cicatrix. It is therefore of 
great consequence to the future appearance of the patients, if 
not to their freedom from consecutive fever, that the pocks 
should be kept from assuming such a condition. Now, on look- 
ing over the person of this woman, I found it to be a rule that 
the grade of destruction bore a direct ratio to the exposure of 
the various parts to the air. The most favored situations were 
the thighs, tongue, and abdomen, next the legs and back, and 
then the hands and forearm. The face was the most purulently 
affected of all. With regard to the back, I should observe that 
it maintained its comparative immunity from advanced inflam- 
mation in spite of the cuticle being much chafed and rubbed off 
in large patches by the movements of the patient. So it would 
seem that oxygen and evaporation, so beneficial to the healthy 
skin, are death to it when diseased, and that the best hope of 
preventing its destruction in smallpox is to defend it from these 
agents. 

To assist, then, the restoration of the skin, in parts important 
to the appearance, I believe it to be a most reasonable practice 
to cover it over with a coating, as impermeable as can be, of col- 
lodion or solution of gutta percha.* This can be easily done on 
the nose, cheeks, forehead, and ears, without interference with 
motion, and the coating itself and the rest of the face may be 
thickly oiled. It is only the most staunch adherents of thera- 
peusis by evacuation that could object to this practice. Another 
rather more antiquated plan is to puncture the vesicles directly 
they are fully formed. The same object is aimed at, namely, 
the prevention of ulceration in the skin, and it is usually attained. 

* Dr. Smart has found that a solution of caoutchouc applied in the same way 
is better; it is elastic, and does not crack and peel off like gutta percha. 



150 SMALLPOX. 

But this latter expedient is rather troublesome, as it runs a chance 
of being roughly and coarsely executed if left to a nurse. 

The depth to which the cutis is injured by the more severely 
inflamed of the pocks is curiously exemplified in the case of a 
young woman readmitted to-day with valvular disease of the 
heart (Eliza M — . Folio 169, p. 20). Her face is seamed and 
graven over with white cicatrices, the relics of a variola by which 
she was aifected years ago. The cicatrices are made more than 
commonly conspicuous by the extreme venous congestion of the 
rest of the skin of the face dependent upon her cardiac lesion. 
This venous congestion was so livid (almost black), that I should 
have been very much alarmed about it, as significative of a dan- 
gerous disturbance of the circulation, had I not remembered her 
as an old patient, and been familiar with her scarred face. By 
experience I knew that a moderate amount of dyspnoea was 
accompanied in her case with extreme congestion of the capil- 
laries of the dilapidated skin. This may serve as a lesson to you 
not to be too soon frightened at the venous blueness of the coun- 
tenance in pock-marked patients. 

You may have observed that the smallpoxed patient's hair has 
been cut short with scissors, leaving it about half an inch long 
all over. The object of this is partly cleanliness, for it is impos- 
sible to keep long hair from being saturated with the discharge 
from the pocks, and then it becomes most fetid. The scalp is 
so sore, from being covered with the eruption, that brushing, or 
combing, or washing is barely possible. Besides which the hairs 
are so much loosened by the purulent condition of the skin, that 
they are easily dragged out in handfuls, almost by their own 
weight, if long. This forcible dragging out injures the hair-bulbs, 
so that they will not sprout again. And it also still further in- 
flames the scalp. So that the best chance for saving the hair is 
to cut it short, since shaving the head is out of the question from 
the pain it would give. 

{Clinical, St. Marys, February 5, 1863.) 

An order from the weekly board to empty the beds and clear 
the wards, on account of the late spread of smallpox among our 



SMALLPOX. 151 

inmates, leaves me no patients to lecture upon, so I will make a 
virtue of necessity and give you a few more remarks on the cause 
of this misfortune. 

Since I took variola as my text three weeks ago, seven more 
persons have contracted it within our walls. They have had it 
in various degrees, and two have died. But as none of them 
have been under my charge, I have not their symptoms to com- 
ment upon. Among the seven was one of yourselves, a house 
surgeon, who had prudently revaccinated himself when he found 
the disease was spreading. While the vaccine pustule was form- 
ing, he found his body overspread with an erythematous blush, 
which he thought at first to be scarlatina, but it soon showed 
itself to be only the forerunner of a variolous eruption. This 
precautionary vaccination was not then completely successful. 
But his attack of smallpox has been very slight, it has not con- 
fined him to bed, and the few scattered pustules are dying off 
without causing any inflammation of the skin. The protection, 
though not complete, was probably still useful. 

To be of use, the poisoning by vaccinia must precede that by 
variola. The eruption of the first must be formed before the 
fever of the second comes on. This is not my own statement, 
but derived from the experience of Dr. Munk, the accomplished 
physician to the Smallpox Hospital, and it is what one would 
a priori have expected. 

You must be careful not to look upon vaccination as in any 
way antidotal or remedial to smallpox. It is not a case of a 
smaller and slighter disease curing a severer one already exist- 
ing; otherwise it might perhaps be taken as evidence in favor of 
either the homoeopathic or counter-irritant theories. It does not 
cure it, or even modify it when already existing. The rational 
view of the relation of the two is this : there exists in the living 
body a certain unknown constituent, which, coming into contact 
with the virus of vaccinia or variola respectively, is capable of 
being converted gradually into that virus, just as surely as a 
thousand hogsheads of malt sugar may be converted into alcohol 
by an ounce of yeast. But when it has once been thus converted 
and passed away, there remains nothing for the virus to act upon, 



152 SMALLPOX. 

and it is consequently harmless. Vaccinating a child is an act 
done on the same principle as cutting off the dew-claw from a 
puppy, lest it should lead to inconvenience in after-life. We 
exhaust or obliterate a useless substance which might lead to 
evil. To call it a remedy in the sense in which medicines must 
be remedies for disease is like calling the removal of the dew- 
claw a cure for a torn leg, or to talk of putting out a conflagration 
by previously removing the inflammable furniture. Prevention 
is not cure, however much better it may be. 

It is obvious that the modification of diseases on the same prin- 
ciple as vaccination is applicable only to those which occur but 
once in life. But there is no reason for the world to despair of 
seeing scarlet-fever and measles rendered as rare, at least, as 
smallpox, by some analogous means. Any plan which offers a 
reasonable chance of success will not now find skeptics to oppose 
it before trial in the ranks of our profession. 

The way in which the smallpox has spread, in spite of our 
efforts at quarantine, shows you how very infectious its nature 
is— how much more infectious than scarlet- fever, measles, ery- 
sipelas, or typh-fever.* I have placed them in the order in 

* I had a striking instance a few months ago of the almost incredible con- 
tagiousness of smallpox. A lady about to be confined summoned her monthly 
nurse on October 29; on November 1 her child was born; on November 12 an 
eruption of smallpox appeared on it, and went mildly and regularly through its 
regular stages, affecting the child's health very slightly. The interest of the case 
lay in tracing the history of infection ; for it is obvious that, allowing two days' 
fever and twelve days' latency, which are invariable in an unprotected person, 
the virus must have been communicated two days before birth. Every one who 
had been in the house positively denied having seen anybody affected with the 
disease, and the mother had not been in a street cab for weeks previously. At 
last it was discovered that after the monthly nurse had left her last place, the 
child she had been bringing up sickened with smallpox and died, and the infec- 
tion was traced to the household of the family washerwoman, whose daughter 
had been laid up with an attack so mild as to be capable of concealment. The 
travels of the virus were, then, as follows: A (the washerwoman's daughter) 
develops it; it is carried in the clean clothes B to the household C, from whence, 
before it has been redeveloped or multiplied by the child who died, it is carried 
by the nurse D to the pregnant lady B ; E, being protected by vaccination, does 
not exhibit it, but passes it on to the child in her womb F within twenty-four 
hours after she first saw the nurse and two days before it came into the world. 



SMALLPOX. 153 

which, in my judgment, there is risk of communication from one 
person to another, viz.: scarlet -fever, measles, erysipelas, typh- 
fever. Of scarlet-fever and measles, most cases are treated at 
home; we have not a dozen cases of each in the wards annually. 
Although I must allow that a good many instances have occurred 
of scarlatina spreading, yet, as a rule, we are able to retain the 
patients in the general wards without its doing so, by the simple 
precaution of allowing an interval of eight or ten feet between 
the scarlatinous bed and the next. So that, without expressing 
an opinion as to the propriety of admitting scarlatina into a 
general hospital, I do not think the matter of sufficient import- 
ance to exclude them by law. Of the communication of erysipelas, 
again, most of you during your pupilage see just an instance or 
so which serve to illustrate the fact. We have not enough cases 
in the wards to supply many examples. But of typh-fever we 
are seldom free, seldom indeed are we long without having many 
more than we like at once. Had it the virulence of smallpox, 
which of the patients, which of the physicians or students, un- 
protected as we are, could possibly escape ? Only an occasional 
rare exception, just enough to prove the facts by tradition among 
you, occurs of its being contracted in the hospital. I can recol- 
lect only three instances in my practice of such having been the 
case. 

But smallpox, in spite of the protection of vaccination, hardly 
ever comes among us without leaving a virus which is most diffi- 
cult to eradicate. Each time that a patient has slept a night in 
the house several others have taken it, each time has a house 
surgeon been infected, and we have got rid of the plague only 
by dint of clearing the wards, whitewashing, and painting, as we 
are now doing. 

Being infectious, then, is not an absolute quality of a disease, 
requiring some one and absolute means of prevention. It is com- 
parative, and has a very different meaning whether it is applied 
to smallpox, or to yellow-fever, or to scarlatina, measles, typh- 

What a notion this gives of the infinitesimal subdivision of matter, and also of 
the powerful protection afforded by vaccination, which guarded the mother's 
body, through whom the virus passed without the slightest injury. 
11 



154 SMALLPOX. 

fever, glanders, syphilis, itch, &c. The means need to be applied 
in very different degrees according as one or the other of these 
complaints are to be provided against. 

The principle indeed involved in the most important of these 
measures is the same ; it is dilution of the virus which is the cause 
of disease, by air and water, before it can come in contact with 
any focus of increase, that is to say, with any human body. 
Chemical "disinfectants" (so called) are useless, unless applied, 
in such quantities as really to be diluents ; and being useless, are 
dangerous, lest they should be trusted to and exclude the employ- 
ment of the really efficient agents. If you advise the use of them 
at all, select the most disagreeable in odor, that thus the servants 
may be driven to dilute the poison by diluting the disinfectant. 
It has been coarsely but truly said that chloride of lime is good, 
for "it makes such a stink, that you are obliged to open the win- 
dows." 



LECTURE XT. 
RHEUMATIC FEVER. 

Relations of the practitioner and lecturer to rheumatic fever — 
Description of treatment — (1) Bedding — (2) Fomentations — 
(3) Remedial agents — Bicarbonate of potash, Iodide of potas- 
sium — (4) Opium — (5) Leeches — (6) Poultices in pericar- 
ditis — (7) Diet — Commentaries on the restorative agencies 
of the aforesaid treatment. 

(Clinical, St. Mary's, May 24, 1862.) 

Rheumatic fever is a pleasant disease — I mean for the doctor 
to treat, though not for the patient to bear. It is pleasant for 
him to treat it, because he then feels himself strong and useful. 
In the first place he can, by the judicious exercise of his art, 
insure the sufferers against several perils to which the nature of 
their complaint exposes them. Again, he can save them much 
pain. Thirdly, he can shorten the otherwise long duration both 
of the illness and of the convalescence. Truly in most diseases 
he can effect one or other of these objects, but in none I think 
so many of them, so surely and so simply, as in rheumatic fever. 

Rheumatic fever is also a pleasant disease to lecture about. It 
presents an unusually uniform type, so that the short descriptions 
you have had in the systematic course of lectures on the practice 
of medicine are found really applicable at the bedside, without 
the necessity for guarding them with all sorts of exceptions and 
variations, which clinical teachers are so often obliged to resort 
to in other cases. The classification I adopt points to a differ- 
ence rather of degree than of essence, viz. : "acute rheumatism," 



156 RHEUMATIC FEVER. 

or rheumatic fever, where there is febrile reaction, shown by 
furred tongue, &c, and "subacute rheumatism" where there is 
none. And a very simple uniform treatment may be recom- 
mended, which hardly ever requires modification. So that if 
your authority with your patient is sufficient to enforce due obedi- 
ence to orders, and you are certain of your diagnosis, you need 
have but little anxiety about the result. 

There are hardly ever absent from the wards specimens of the 
mode of treatment I adopt. My present business is to tell you 
my reasons for the plan pursued. 

But first let me speak of the plan itself. 

1. The patient's bed is made in a peculiar fashion. It is a 
standing order that .no linen is to touch the skin. A slight calico 
shirt or shift may be allowed; but if the patients possess under- 
clothing only of the prohibited sort, they are better naked. Even 
a linen front to the shirt is dangerous. Sheets are removed, and 
the body is carefully wrapped up in blankets, which are so arranged 
as shut off all accidental draughts from the head. The newest 
and fluffiest blankets that can be got are used. 

The bedclothes being put so, are kept so, and the attendants 
and students are warned that when the sounds of the heart are 
listened to, they must not throw off the wrappings, but insert a 
stethoscope (first warmed) between the folds. 

2. Those joints or limbs which are swollen, red, or painful, are 
wrapped up in flannels soaked with a hot fomentation consisting 
sometimes of plain water, sometimes of decoction of poppy-heads 
with half an ounce of carbonate of soda to each pint. 

3. The following drugs are prescribed with a curative intention. 

(a) If the skin is red, swollen, and painful about the joints — 
if the cellular tissue around the muscles is infiltrated and sensi- 
tive, so that motion is impossible or exquisitely painful — more 
especially if these phenomena are metastatic, leaving one part 
free and attacking another; — patients have then the " alkaline 
treatment" pure and simple: they have a scruple of bicarbonate 
of potash in camphor water every other hour, night and day, 
when awake. 

(b) If the above symptoms are insignificant, and the pain is 



i RHEUMATIC FEVER. 157 

felt more in the bones — if it is intensified rather by pressure 
than by motion — if it is fixed in one spot a,nd not metastatic; 
— then I add two grains of iodide of potassium to each dose; 
and directly the symptoms have taken a turn toward allevia- 
tion, I leave off the alkali altogether, and give only the iodide 
of potassium. 

4. Opium is given in exact proportion to the degree of sub- 
jective sensation of pain. If one grain be not enough to entice 
sleep, a grain and a half is administered; if that do not avail, 
two grains. Directly the pain is relieved, the quantity of the 
drug is diminished. Nothing effects the desired object so well 
as pure opium in pill or in tincture. 

5. If the pain remains fixed in one joint, instead of leaving it 
as it leaves other places, leeches are applied there, and the part 
is kept poulticed. Sometimes bruised laurel leaves are mixed 
with the poultice. 

6. Leeches and poultices are also applied to the cardiac region, 
if the heart has become inflamed either inside or out. The pain 
felt is taken as an indication of the extent to which the leeching 
is to be pushed, so soon as it is proved by auscultation that such 
pain arises from inflammation of the heart, and not from rheu- 
matism of the pectoral muscles. The constant application of 
the poultice is made imperative after the leeches. 

7. The diet is varied in some degree according to the social 
and personal state of the patients. If they have been hearty, 
well-to-do persons before the attack, they will bear a good deal 
of starvation, and are accordingly put on our "simple diet;" to 
wit, bread and butter, gruel, and tea. If previously they have 
been ill nourished, by reason of either ill health or poverty, or 
if they have been ill for some time, a pint of broth or beef-tea 
is added. 

I will now proceed to comment on the several items of treat- 
ment in the order in which I have placed them. 

1. Bedding. — It is impossible to make too much of the value 
of absolute rest and an evenly high temperature to the skin in 
rheumatic fever. They are worth all the other means of relief 
put together. Since I have succeeded in getting our nurses to 



158 RHEUMATIC FEVER. ' 

adopt them as a universal rule in every case of rheumatic fever, 
without exception, I have had hardly any patients to treat for 
inflammation of the heart.* 

The rationale of the action of warmth is very simple. Rheu- 
matic inflammation is an injury to nutrition which is entirely 
compensated for by the restored function on return to health. 
Rheumatic inflammation passes away and leaves no after-sign, 
no wound no scar. This only happens, however, if the parts 
affected are kept perfectly still. Should duties be asked of them 
which they are unable to perform in their imperfect condition — 
should necessity or ignorance lead the patient to keep moving a 
swollen joint, for example, then common inflammation is super- 
added. Then the pain and swelling become fixed, and no me- 
tastasis can take place. You see this frequently in poor working 
people, who, through need or ignorance of what is likely to 
follow, strive to go on with their business up to the last minute. 
Laborers come into the hospital with the disorder fixed in their 
knees, carpenters in their elbows, laundresses in their wrists ; so 
that you may make a shrewd guess at their trade from the part 
where the disorganizing inflammation is situated. Pain may be 
called the proof of beneficent design in God's laws as shown in 
disease; it is a warning to withhold one's self from that which 
excites it. The pain of rheumatism is a call to voluntary abso- 
lute rest. K*ow, in the joints this is easily obtained, and, under 
any treatment, you hardly ever see disorganizing inflammation 
begin in a joint after a patient has once taken to his bed. But 
there is one organ whose business admits of no rest; — the heart 
must needs keep beating at whatever cost; — and the heart ac- 
cordingly is well known to be fatally apt to be struck with 
common fibrinous inflammation at all stages of rheumatic fever. 
Taking a lesson from what I have noticed in the joints, I try 
and assist the heart to gain, not of course the Utopia of absolute 
rest, but the nearest approach that is possible. 

Perhaps you may think that object would be gained by simple 
confinement to bed in the horizontal posture. It is not so. Next 
to jumping and running, there is nothing gives the heart so 

* On this point see the statistics in the next Lecture but one. 



RHEUMATIC FEVER. 159 

much work to do as alternations of heat and cold. Let the 
physiologist observe the healthy organ, let the physician ex- 
amine it in a state of disease, and they will find that a change 
of temperature on the surface of the body is followed by a longer 
and stronger stroke as felt by the finger, by a longer and stronger 
sound as heard by the ear in the cardiac region. The interval 
between the strokes is shortened; and thus is encroached upon 
the only wink of sleep the hard-working muscle ever indulges 
in. What does the accoucheur do who wishes to apply the 
strongest vivifier to the dormant nerves of a still-born baby? 
He dashes cold water and cold air on the skin, — he rubs the 
chest dry and applies hot cloths apace, — again he dashes it with 
cold, — making as many changes as he can. What the accou- 
cheur is so anxious to accomplish there, we are most anxious to 
avoid here ; and I feel sure that it is by virtue of screening pa- 
tients with rheumatic fever from the influence which variations 
of heat and cold have over the dependencies of the pneumogas- 
tric nerve that the treatment now advised is so successful. I 
never have pericarditis come on when it is once fairly begun and 
persisted in. 

I scarcely need to say that the most important part of the 
person, as respects the attainment of the accoucheur's object, 
and our opposite object, is the chest. There he applies his 
"stimulus," and there we must as carefully watch against it. 
A patient of mine at this hospital (year 1859, No. in Reg. 711) 
got pericarditis by being dowsed with cold water on the face 
and neck for an hysteric fit accidentally occurring during con- 
valescence from rheumatic fever. And as a student I used to 
see many and many a case of pericarditis brought on by the 
careless way in which the thorax was bared in the daily stetho- 
scopic examination. It is doubtless necessary to listen to the 
heart thus often, in order to convince ourselves of the absence 
of morbid sounds: but by. warming the stethoscope in our pocket 
or under the axilla, and making the blanket into a tube by which 
to insert it, we cause the least possible degree of danger, and 
avoid the merited accusation of meddling to the patient's hurt. 

You saw a fortnight ago an instance of the danger of the 



160 RHEUMATIC FEVER. 

exposure I have been deprecating. Margaret K, aged 23, was 
admitted March 28 for rheumatic fever, with swellings in the 
arms and legs; from this she recovered perfectly without any 
affection of the heart, and was transferred to the convalescent 
ward. On April 17 she had a relapse, principally affecting the 
legs, and on the 19th I found her in bed again. By an oversight 
she had not been blanketed, and, when I felt the cold sheets damp 
with the patient's perspiration, I was not surprised that she com- 
plained of constriction across the chest. You heard me rebuke 
the nurse in no measured terms, and prognosticate evil. With 
justice; for before two days were over there was a melancholy 
systolic murmur distinctly audible. I trust this case has been a 
warning to you. 

"I. Fomentations. — By comparing in occasional cases one limb 
wrapped in fomentations of simple hot water, with another where 
decoction of poppy-heads was used, I have come to the conclu- 
sion that either the viscid vegetable matter, or the small quan- 
tity of opium in the poppy-heads, contributed toward alleviating 
the pain a little. And a similar experiment has led me to the 
same opinion as respects an alkaline carbonate. But the heat 
is the most important element in this part of the treatment. 
Look well after your nurses, and see that they keep the foment- 
ation warm. 

3. Curative Drugs (a). — With unimportant exceptions, I have 
treated every patient for the last seven years with bicarbonate 
of potash, being convinced of its power to shorten and alleviate 
the disease by daily experience as well as by the statistical de- 
ductions of Dr. Garrod. In a great majority of the cases very 
rapid relief commences with the commencement of the treatment, 
and continues permanent. But in a certain number no effect 
appears to be produced, sometimes even after the urine* has been 
made alkaline. In a few of these there has been committed a 
pardonable error of diagnosis, — the patient is gouty. In a few, 
also, we are deceived by gonorrhoeal rheumatism, a disease allied 
to pysemia, and requiring quite different management. Still 
there are a certain number of instances where true rheumatic 
inflammation is very obstinate and does not yield to the alkaline 



RHEUMATIC FEVER. 161 

method. And in these you will find the periosteum and peri- 
chondrium affected. When the patient, then, after five or six 
days of the alkaline treatment, is no better, or hut little better, 
I add, as I told you, iodide of potassium to the potash, and in a 
few days more continue the iodide alone during the convales- 
cence. Of course, if I am enabled to make this condition of 
the periosteum out at the first visit, I begin such treatment forth- 
with. 

I mentioned just now that I had, in a few instances, for ex- 
ceptional reasons, not given the alkaline treatment for rheumatic 
fever. Among those are included a middle-aged laborer and his 
wife, both attacked together and just recovered, in which cases 
you saw no drugs given during the acute stage. The object of 
this omission was partly to test a suspicion that the alkalies might 
cause or augment the anaemia and weakness so general in the 
convalescence of rheumatic fever, or perhaps might give rise to 
relapses by checking the course of the disease. These two cases 
did much to disabuse me of that fear. We saw that the loss of 
flesh and strength was in both husband and wife as great as 
usual, if not greater than in the majority of examples which 
come before us in the wards — satisfying us that it is the disease, 
not the remedy, which is to blame for the usual emaciation and 
weakness. We saw, also, that one of the patients (the man) had 
a relapse, showing that to nature and not to art is to be attrib- 
uted this unfortunate occurrence, so frequent in rheumatic cases. 
Partly also, in these two cases, I omitted drugs, to use them 
as a pretext for reminding you that you do not carry in your 
medicine chests any absolute or indispensable powers — to show 
you that rheumatic fever is a state in which the forces of life 
move in a circle, in a road which leads of itself back toward 
health, and is not a chronic disorganizing process, whose path 
may be drawn as a straight line, approaching nearer and nearer 
to death the farther it goes. It ends of its own accord, or at all 
events without the aid of drugs, often in a few days, often (a& 
you saw here) in a time quite as short as could have been ex- 
pected had medicines been administered. This consideration is 
needful to enable you to rate duly the value of numerical argu- 



162 RHEUMATIC FEVER. 

ments, and to understand that a very large collection of cases, 
much larger than any experience in private practice ever can 
supply to you, is needed to prove the ability of a drug to shorten 
rheumatic fever. If you forget this, you risk being misled by a 
fallacy, with an instance of which applied to experience of this 
very disease I was amused a few years ago. I had an interview 
with an irregular practitioner (very irregular indeed), who told 
me that he gave no medicines, but followed "the method of St. 
James" — -he "anointed with oil them that were sick, and the 
Lord raised them up." As proof of the success of his plan, he 
gave me the history of two attacks he had undergone of rheu- 
matic fever. In the first he was treated professionally, and was 
laid up for more than three weeks ; in the second he obeyed the 
perversion of Scripture above quoted, and was out of bed in five 
days. Of course he was perfectly impervious to argument. 

Do not misunderstand my words, or interpret them as if I 
intended to ridicule the proof brought hj Dr. Garrod of the 
success of the alkaline treatment in shortening the average 
length of our patients' pains. I think his calculations fairly 
prove that point, though they do not show that the whole dura- 
tion of the disease is less. But my principal reason for adopting 
them is that the use of such drugs is quite in harmony with the 
principles of restorative medicine. The deficiency of alkali ^in 
the body is shown in all quarters by the appearance of free acids. 
In indubitable cases of rheumatic fever left without treatment the 
sweat is acid, the saliva is acid, the urine, instead of being mod- 
erately acid, is intensely acid ; the breath even smells acid. The 
blood, indeed, remains alkaline, fortunately for the life of the 
patient; but that only is done at the expense of becoming ex- 
ceedingly watery, and producing the anaemia which is. so charac- 
teristic of the convalescence of rheumatic fever. If the blood is 
aqueous, and contains less solids than normal, at the same time 
that the salts bear their usual proportion to the rest of the solids, 
it is obvious that there must be a great deficiency of those salts 
in the body. Though the blood be not acid, it is easy to under- 
stand that it carries less alkali than it ought to do. 

A real deficiency is attempted to be replaced by the carbon- 



RHEUMATIC FEVER. 163 

ated alkali. And when we think how great is the mass of living 
matter over the whole of which this great deficiency exists, then 
is explained the need for large and repeated doses, which all 
good observers insist upon. To give a few grains three times a 
day is mere playing at healing, and cannot be reckoned as treat- 
ment at all. I do not think anything less than half an , ounce 
of the bicarbonate of potash in the twenty-four hours is of real 
use. Again, if this runs off straight by the kidneys, making 
the urine alkaline too quickly, it is of little avail; but if it 
mixes with the mass of the corporeal fluids, and is some time 
before it is found by its alkaline reaction in the renal secretion, 
the good effect is sensibly felt by both the patient and his 
attendants. 

Again, I do not think it a fair trial of the treatment to give 
the potash neutralized by an acid, as tartaric or citrate. These 
salts may be good for rheumatism, but they do not test Dr. 
Garrod's statistics. And similarly, larger doses at longer intervals 
do not fulfill the indications. 

A collateral advantage of frequent doses is the more attentive 
nursing which it insures. In these oft-repeated visits the attend- 
ant looks well after the arrangement of the bedding, sees that 
no part is left exposed to the air, and as our naval friends say 
" makes all taught." 

(5) The employment of iodide of potassium is more empirical. 
By none can the fact be explained that this remarkable sub- 
stance restores their normal functions to several tissues — most 
notably to those sparingly supplied with blood-vessels, such as 
cartilaginous and white, hard, fibrous parts, the periosteum, the 
sheaths of tendons and of nerves — and even influences the hair, 
the nails, and the outer layers of skin. Iodide of potassium is 
of signal service when rheumatism or gout attack the tendons 
or the thecse inclosing the muscles and tendons. I think we 
cannot doubt the words of the sufferers when they say that they 
feel the better for it, however inexplicable the fact may be. 

The earlier in the disease that iodide of potassium be given 
the quicker it acts. You may see this to be the case in syphi- 
litic periostitis, which when recent, yields rapidly, and when of 



164 RHEUMATIC FEVER. 

long standing, yields but slowly, to the influence of the drug. 
So is it in rheumatism ; the old chronic cases are aided by 
iodide of potassium, indeed, but prove as a rule very obstinate ; 
while this aifection of the white fibrous tissues which follows 
rheumatic fever, and which we are now concerned with, is usually 
removed in a few days, because it is taken in hand at an early 
period. 

4. Opium. — This is given purely as an anesthetic. There is 
no reason to think it either shortens or lengthens the time the 
disease lasts. Curiously enough, it does not usually stop the 
action of the bowels so long as the painful condition remains 
which it is given to lighten. Should constipation follow, the 
inconvenience is easily obviated by adding two or three grains 
of good extract of colocynth to the opium pill. 

5. Blood-letting. — The treatment by leeches and poultices of 
the common inflammation which may sometimes override the 
rheumatic in joints moved about during their weak state, has 
nothing special about it. It may generally be depended upon 
to prevent disorganization, because in point of fact the inflam- 
mation is very slight and diffused. 

6. Carditis. — I have told you inflammation of the heart does 
not come on in patients who have once been placed and kept under 
the treatment detailed to you. But in a good many instances 
the exposure the poor people have been subjected to previously, 
and sometimes the necessary time spent in our waiting-room, 
gives you an unlucky opportunity of seeing me treat this com- 
plication. If it is found out within twenty-four hours of coming 
to the hospital, it is of course registered as due to the circum- 
stances I have named, and our nursing is not to be blamed for 
it. I feel satisfied that it need make no difference in the appli- 
cability of the alkaline method ; indeed it rather strengthens 
my resolution to insist on this being fully carried out. It 
determines me also to be more than usually watchful about the 
maintenance of temperature by blankets, and to take care of the 
chest in special by continuous poultices. When cardiac symp- 
toms are detected, when there is friction or a murmur detected 
by the ear, or even when pain is felt on pressure of that vital 



RHEUMATIC FEVER. 165 

part, from six to twelve leeches are forthwith applied ; these 
usually relieve the pain somewhat ; but if it returns again next 
day, they are to be repeated, and this may be done again and 
again, as long as pain lasts. The pain is the best measure of 
the acuteness of inflammation in serous membranes ; and so long 
as acute inflammation remains, leeches and poultices are the 
best remedies for it.* To mercury I have never been able to 
trace any advantage at this stage ; indeed, I am not sure that it 
does not dispose to pericarditis by increasing the proportion of 
fibrin to the other constituents of the blood. Perhaps after 
effusion has taken place it may be useful, but I am not quite 
satisfied that it is desirable in all cases even then. 

Opium may be given in full doses ; and far from being contra- 
indicated on the score of cardiac inflammation, it is all the more 
urgently called for. For it certainly does control and lower 
the hurry of circulation which is so dangerous. Under its use 
the pulse is diminished in frequency, sometimes even below the 
normal standard ; and this must surely be an important object 
in a diseased state brought about by the continuous motion of 
the heart. 

The treatment of pericarditis brooks no delay. Lost minutes 
are more hurtful here than in any disease I know of. Send 
for leeches and have them applied immediately that your sus- 
picions are aroused by an abnormal murmur, and if they are 
not at hand, cup the cardiac region. It is better even to antici- 
pate evil than to be too late. On this principle you saw me a 
fortnight ago leech and poultice the heart of the young woman 
before mentioned (case of Margaret K.), where you could hear 
no friction in the pericardium, and you wondered at my "sharp 
practice." But the fact is, it was a case of relapse ; and as the 
patient slept in the convalescent ward, the nurse carelessly 
neglected to wrap her in blankets : the cold damp linen was 
beginning to do its work, and the lengthened heavy stroke of 
the left ventricle, accompanied by a sense of tightness and pain 
on pressure, warned me to try and prevent the threatened 
inflammation. I was only partially successful ; the foreseen 

* This subject is fuller treated in a subsequent Lecture, 



166 RHEUMATIC FEVER. 

evil did come ; in two days' time an exo- cardial murmur was 
distinctly heard. But I am sure the pericarditis was in a much 
milder form than it would have been had leeches not been 
applied. 

7. Diet.— In rheumatic fever there is a painful necessity for 
restricting the supply of an important class of nutriment. If 
meat be given, it seems to turn into lactic acid, at all events it 
adds to the quantity of organic acids in the body. The power 
of fully converting it into living flesh is wanting, and until this 
power is restored, a semi-conversion into the substance named 
takes place. 

Even when the pains are gone and there is such an urgent 
call for replacing lost flesh, the most suitable diet for supplying 
it will sometimes bring on a relapse. Hence I find it needful 
to give patients less food than their feelings prompt them to 
take. The redder and more muscular it is, the more it seems to 
disagree, and you must very cautiously get back to " ordinary 
diet," else you run a risk of losing more by a second attack of 
the disease than is to be gained by haste. Vegetable matter 
does not expose patients to the same danger, and ttus by dint 
of rice pudding, porridge, gruel, bread, mashed potatoes, and 
the like, you may try to satisfy the mouths which often loudly 
complain of starvation. If, however, you cannot, by such per- 
suasion, succeed in staying the appetite, it is your duty to be 
cruel, for observation will soon convince you of the hurtful effects 
of animal food in causing relapses. 



LECTURE XII. 

RHEUMATIC FEVER. 

Exceptional cases of rheumatic fever — Inflammation of heart 
arrested by epistaxis — Delirium and gangrene in rheumatic 
fever — Treatment — Case of rheumatic fever in a tubercular 
subject, with consecutive purpura of the legs — Treatment by 
lemon juice. 

(Clinical, St Mary's, June 27, 1863.) 

A young woman with rheumatic fever in the corner of Victoria 
Ward was found the other day by the house surgeon, Mr. Mahon, 
to be suffering from pain in the cardiac region increased by firm 
pressure. Although he could detect no abnormal sound on 
auscultation, yet he thought it advisable to order half a dozen 
leeches to be applied to the part. He was wise, I think, in so 
doing ; for the course followed by inflammation of the heart in 
rheumatic fever is this ; — first the rheumatism, such as you see 
it and feel it in the limbs and joints, settles in the heart, just as 
it might settle in any other part, and as in any other part with- 
out common or disorganizing inflammation ; — but, as in any 
other part, motion will change the rheumatic into disorganizing 
inflammation ; and therefore as you cannot stop the heart's 
motion, you must try and get rid of the rheumatism quickly, 
and for the time only perhaps, but at any rate for the time, 
from this dangerous locality. And you must not mind making 
some sacrifice to accomplish such an important object. Now, 
local blood-letting does do this even in the joints, only that it is 
not in general worth while to get rid of the rheumatism, out of 



168 RHEUMATIC FEVER. 

the knee for example, when in half an hour it may come on just 
as bad in the hand. But in the case of the heart it is worth 
while, well worth while, to do much more (if wanted) than putting 
on a few leeches. 

But do the leeches really prevent it in a natural and physio- 
logical way ? This case has shown you that the treatment is 
entirely in accordance with nature (if that is any recommenda- 
tion) and reasonable physiology. Though ordered, the leeches 
were not put on — and why ? Because in the mean time the 
woman's nose burst out bleeding, and that event entirely 
relieved the pain in the heart, and most completely justified the 
prescription which had been written. 

I do not want you to accept the epistaxis as an " effort of 
nature," designed to relieve threatened carditis ; for, as a matter 
of fact, any idiopathic haemorrhage is very uncommon under 
such circumstances — but as a fortunate accident. If it had any 
design at all, it was designed to teach you medicine ; to teach 
you that a very moderate loss of blood may avert a great 
danger. 

But I have spoken of loss of blood even in moderation as a 
sacrifice. And it is so peculiarly in rheumatic fever. The 
disease is one which, cseteris 'paribus, attacks the weakest persons 
at their weakest times ; women, children, the aged, the debili- 
tated by sickness are the most liable, if exposed to the usual 
causes. And not only the weakest persons, but the weakest parts- 
of those persons. I admitted a man named Amos F. into 
Albert Ward on June 12, with rheumatic fever. Two years 
ago he was in this hospital for paralysis of the right arm and 
leg, in consequence of some cerebral lesion probably, and he has 
never recovered full power in the upper extremity. Since then 
he has had rheumatic fever tw T ice, this being the second occasion, 
and both times the right elbow and hand have been the place 
first affected, and the place longest and worst affected both with 
pain, and swelling, and redness. If then rheumatic fever affects 
by preference the weakest flesh, it is right to view everything 
that weakens the flesh a sacrifice. In that light we must con- 
sider loss of blood, prudent and wise though the sacrifice may be. 



RHEUMATIC FEVER. 169 



{Clinical, St. Mary's, October SI, 1868.) 

Exceptional cases occur seldomer in rheumatic * fever than in 
any other disease I can at this moment call to mind. Yet they 
do occur ; and there is now in the wards one noteworthy instance 
of rare symptoms and rare treatment, both markedly different 
from what I have described as those of at least ninety-nine out 
of a hundred of the patients you will have. For this hundredth 
case you ought to be prepared. 

The fever of acute rheumatism bears the type which our 
grandfathers called "synocha," and our fathers "inflamma- 
tory;" that is to say, the relations of the senses and the mind 
are not impaired in the direction of either obtuseness, coma, or 
delirium ; there is no tendency to the local death of tissues or 
gangrene ; and the congestions which may intervene result in 
active and fibrinous inflammation. But occasionally it exhibits, 
from the very beginning, the character of typhus ; the nervous 
system is deeply affected in its most important functions, there 
is an excessive depression which may end fatally, and a great 
danger also from sloughing of the parts compressed in the 
recumbent posture. 

Such are the peculiarities in the instance of George R.., re- 
ceived as an urgent case in the middle of last week, October 
21. He is a wiry little letter-carrier, only twenty-four years 
old, who has never before suffered from any serious illness. He 
has a happy home, and a merry, affectionate wife ; is active, 
prosperous, and intelligent, employing his leisure hours in playing 
the organ at a neighboring church. I recount these particulars 
to show that his antecedents are not of a noxious kind. On the 
7th of October he cleared out a dirty cistern and got very wet 
and cold. On the Qth he felt out of sorts, and took a hot bath. 
This exhausted him, and he also got chilled in coming home. 
Pains in the limbs came on, and on the 11th he was laid up in 
bed with increased pain accompanied by swelling and redness in 
the joints. He then had another hot bath, after which he was 
still worse. His wife perceived then that his mind began to 
12 



170 RHEUMATIC FEVER. 

wander from time to time, and before his admission, on the 21st, 
the delirium was constant and of a violent character. The 
wrists, hands, one ankle, and the other knee were red and much 
swollen, and in the knee-joint the fluctuation of fluid could be 
felt. But during his ravings he moved these limbs about, seem- 
ingly regardless of the pain which is usually so acutely felt in 
rheumatic fever. His tongue was of a yellowish brown and 
nearly dry, the lips and teeth were parched and brown with 
sordes. The skin was sometimes dry, sometimes bathed in a 
profuse sweat of a rancid, sour odor. His chest was covered 
with a copious eruption of sudamina. His pulse was variable, 
seldom above 100, however. His bowels were constipated ; but 
after a dose of castor oil they were normal in action. A stetho- 
scopic examination of the chest proved the heart and lungs to be 
free of any inflammatory lesion, their sounds being quite healthy. 
He became so noisy and violent at night that he was obliged to 
be moved into a room by himself, and then his delirium assumed 
a more rambling form, and he made no more spasmodic attempts 
to get out of his blankets. 

I saw him the next day, the 22d, and ordered — ^ Opii, gr. j. 
omni node. ^ Potassi iodini, gr. xv ; Ammonim sesquicarb., 
gr. iv ; Decocti cinchanse, oj« ^tis horis. Six ounces of fort 
wine daily, and a cup of beef tea every two hours. 

His delirium and low typhus symptoms continued till the 
25th, but on the 24th he was sufficiently quiet to be moved up 
into the ordinary ward. On the 24th the spine of his back was 
noticed to be red, and on the 28th it is noticed in the case-book 
that a small slough had formed on the sacrum. His tongue 
however had got quite clean, and he had not been delirious since 
the 25th. The pain, swelling, and redness had all disappeared 
at that date. 

Such is the history of a more than ordinarily satisfactory ter- 
mination of typhus rheumatic fever. I have seen several end 
fatally, and was at first very anxious about this young man, and 
was all the more anxious from some answers he gave to our first 
questions having induced a notion that he had been suffering 
recently from gonorrhoea ; and I thought it just possible that we 



RHEUMATIC FEVER. 171 

might have to amend our diagnosis, and that it would turn out a 
case of urethral pyaemia affecting the joints. This unworthy 
suspicion was however taken away by the indubitably correct 
account his wife was able to give of his freedom from that dis- 
grace, and his own assurance when he recovered his senses. 

You may have remarked that in relating his history I impli- 
citly attributed some part at least of the severity of the disease 
to the hot-water baths taken. Possibly you may think this 
accusation of mine somewhat inconsistent with my keeping 
rheumatic fever patients in a sort of perpetual warm bath, by 
wrapping them up in fomentations and blankets ; so I take this 
opportunity of teaching you that the two operations are not only 
essentially different, but essentially contrasted with one another. 
A hot- water bath involves too great changes of temperature, a 
rapid one from the original heat to a degree above the original, 
and a slower cooling afterward. Packing in blankets with con- 
tinuous fomentations not only keeps the production of animal 
heat even, but it also defends the patient against external varia- 
tions. So that where one does good, we may reasonably con- 
clude that the other does harm. 

About the treatment I do not wish to say much, except that 
it was in the highest degree stimulant and nutritious, in marked 
contrast to that which I find adapted to ordinary cases of rheu- 
matic fever. I have never administered iodide of potassium 
before under the same circumstances, but I think I shall again. 
Bark and ammonia alone I have given on former occasions, but 
not with equally good results. 

You will have observed that my first act on hearing the history # 
was to apply my stethoscope to the heart, and then to the lungs, 
although there was no account of any symptoms referrible to 
those viscera. The fact is that delirium, which is the secondary 
result of pneumonia or pericarditis in rheumatic fever, usually 
masks its cause, and violent inflammation may go on without 
showing any external evidence of its presence. It is right 
therefore to look for these local inflammations, for in point of 
fact delirium of such an origin is more common than that which 
we see here with lungs and heart healthy. 



172 KHEUMATIC FEVER. 

The delirium in both cases I believe to be of the same nature, 
to be in itself indicative of the same pathological condition of 
the nervous system, and to be suggestive of the same line of 
treatment, whether it exists along with thoracic inflammation or 
without thoracic inflammation. I believe it indicates a threat- 
ening of death by the nervous system, which must be warded off 
as you have seen it warded off here. It is only when rheumatic 
pneumonia and pericarditis have gone too far to admit of de- 
pletory or debilitant measures, or occur in a frame already dis- 
posed to typhous depression, that they impair the cerebral func- 
tions. When therefore delirium supervenes, I would advise you 
to treat any inflammation of the heart or lungs which you may 
find with it, in such a way as not to interfere with your bark 
and your wine and your opium. 

There are two ways in which the pathology of these low forms 
of rheumatic fever may be explained. 

First, it is not impossible that a zymotic poison may enter at 
the same time with, and combine to form a new compound influ- 
ence with the. influences which originate the rheumatism. And 
such an explanation would chime in very well with the history of 
the case under our eyes ; for the man says his ailment was 
caused by cleaning out a foul cistern, where decaying organic 
matter would be the suitable birthplace of febrile malaria. But 
I have not been able to trace this kind of evidence in other 
instances. 

Secondly, we may view it as an imitation rather than as the 
child of typh-poisoning. The symptoms by which we recognize 
1 the action of that virus are especially exhibited in the nervous 
functions — the rigors, the languor, the delirium, are witnesses 
of death in the nerves; and when such death in the nerves is 
due to other causes, the same symptoms arise. Hence you have 
the low, or typhous, state arising after severe injuries of al 
kinds, when the destructive consequences of those injuries arrive 
at the nervous system. This may, under special circumstances 
of which we are ignorant, be the exceptional case in rheumatic 
fever. 

Neither view modifies the treatment. 



RHEUMATIC FEVER. 173 



(Clinical, St. Marys, December 12, 1863.) 

In Cambridge % Ward is an example of rheumatic fever, which 
has lain in the hospital longer than the usual time, and is not 
yet fit to be discharged. The patient is a carman ; John H., 
aged 26, admitted November 7. The peculiarity that distin- 
guishes it from the ordinary run of cases is, that he has consoli- 
dation, detectible by bronchial breathing, and presumably tuber- 
cular, of the upper lobes of both lungs, and copious muco-purulent 
secretion from the bronchial membrane (chronic bronchitis) in 
consequence of it. Whenever he is put upon low vegetable diet 
and sweated in blankets, his rheumatic pains and swellings of 
the joints subside as readily as do those of other patients ; but 
then he grows terribly weak, and the expectoration increases in 
quantity and purulence, so that we have to give him full allow- 
ance of animal food and quinine. This brings back the semi- 
acute swellings and pains, with sour rheumatic odor in the 
sweat, and even some degree of fever. Iodide of potassium has 
not prevented these relapses, which have occurred three times. 

In examining his legs on the occasion of the last relapse, I 
found around the ankles a copious crop of pin-head specks of 
purpura. On this indication, I ordered him three ounces of 
lemon juice daily, and the treatment seems to succeed very well, 
for he is gaining strength now without relapsing, although eat- 
ing meat daily. 

Had this man been treated by alkalies, it is most likely some 
of us would have attributed his purpura to that cause. But the 
rheumatism, in its acute stage, was alleviated only by the usual 
blanketing and low diet. And moreover, I take this opportunity 
of saying that, whatever may' be the defects of the alkaline treat- 
ment (which I am not going to discuss now), the production of 
purpura is not one of them. I have not seen such scorbutic con- 
dition more frequently among rheumatic fever patients so treated, 
than among others. 

This seems to me just one of those specially circumstanced 
cases of rheumatic fever where lemon juice is suitable, and I 



174 RHEUMATIC FEVER. 

think that it was from the obvious advantage derived from it in 
similar instances that its credit as a remedy has been gained. 

The difficulty of trimming the dietary where one complaint is 
to be benefited by starvation and another by higji feeding is very 
great, and it is a most fortunate circumstance that this com- 
bination is rare in the case of rheumatic fever, which seldom 
occurs in comsumptive persons. 



LECTURE XIII. 
RHEUMATIC F^VER. 

Therapeutical Statistics. 
(Clinical, St. Mary's, January 9, 1864.) 

Statistics, like many other excellent things and people, are 
apt to prolong themselves into bores, and in so doing lose much 
of their legitimate force. It will be my aim therefore to make 
this lecture as short as I can. 

Between June 1851 and Christmas 1863 there have been in 
the wards under my care at St. Mary's 257 cases of rheumatic 
fever. Of these (cases under treatment on Christmas day not 
being included) — 

26 were treated with 5j of niter three times a day ; — 
174 were treated with bicarbonate of potash — viz., 
141 with 3j, or more, every two hours ; — 
33 with a less quantity ; — 
32 were treated, during the first year, in various other 

ways;— 
25 (that is to say, all since May last) have had none of these 
supposed curative drugs ;* only a little opium when the 

* I suppose it is natural, as one advances in years, to adopt milder and milder 
methods of treating rheumatic fever. Sydenham did so. In 1675, the date of 
the third edition of the " Observations Medicas," he was trying the " curatio 
repetitis vense-sectionibus :" in 1680 he writes to the Warden of Caius College, 
Cambridge, " verosimile esse judicabam morbum diseta simplici, admodum 
refrigerante, et mediocriter nutriente, agro imperata, asque feliciter ac repetitis 
venee-sectionibu.s profligari posse; etiam evitatis, quae alteri methodo adjunge- 
bantur, incommodis : neque me fefellit dieeta e sero lactis phlebotomise loco 
substituta." This is repeated in the revised edition of the " Epistola? Re- 
sponsoriae," date 1685. 



176 RHEUMATIC FEVER. 

pain was very severe, and a purgative when the bowels 
were abnormally costive. 
No selection of cases was made, but each method was adopted 
in every case for a time. 



1. Results of drugs on the duration of illness. 

Of the 26 treated with niter, the mean stay in hospital was 
40-0 days. 

Of the 141 treated with the 3j bihoral doses of bicarbonate 
of potash, the mean stay in hospital was 34*3 days. 

Of the 33 treated with less quantities of the potash, the mean 
stay in hospital was 40*0 days. 

Of the 25 treated without curative drugs, the mean stay in 
hospital was 27*7 days. 

If we exclude the last class, which is as yet imperfect for 
statistical purposes, as it does not include examples of all the 
four seasons, it would seem that, though smaller doses exert no 
effect, yet that full doses of the bicarbonate of potash have some 
influence in shortening the duration of the illness from the time 
of commencing the treatment to that of the patients being 
sufficiently convalescent to return to their usual occupations with 
safety. 

I may remark here, that any other measure of the duration of 
the disease is quite untrustworthy for statistical purposes. The 
different degrees of susceptibility to pain exhibited by different 
patients, the desire of some to extenuate, of others to exaggerate 
their sufferings, makes it impossible to register truly even the 
exact day when the pain ceases. Whereas, in such a short 
period as it lasts after the commencement of treatment (namely, 
two or three days usually), the exact hour would require to be 
noted. It is equally impossible to measure when, or even 
whether, the swelling or redness is all gone. Those who have 
set clinical clerks to observe these facts know how little the case- 
books are to be relied on. 



EHEUMATIC FEVER. 177 

2. Results of drugs on the consequences of the illness. 

In respect of their several preservative powers against the 
consequences of rheumatic fever — 

Of the 26 treated with niter, there were attacked with acute 
inflammation of the heart while under treatment (carefully ex- 
cluding all those admitted with it already existing as a result of 
the current attack) 5, or 19*2 per cent. (4 cases of pericarditis, 
1 endocarditis only) ; 4 have died — 2 of inflammation of the 
heart, and two of sloughing back. 

Of the 174 treated with bicarbonate of potash, there were at- 
tacked with inflammation of the heart 9, or only 5*3 per cent.; 
none have died. 

It would seem from this, at first sight, as if bicarbonate of 
potash had some preservative force. But the fact is, that nearly 
all of those treated by the alkaline method have been subjected 
also to what both rational physiology and the statistics following 
seem to show has a much more powerful influence than any other 
drug in keeping the heart free from inflammation. I refer to 
blanketing the patients. 

3. Effects of blanketing. 

Up to May, 1855, no difference was made in the bedding of 
my patients with rheumatic fever from .that of others in the 
ward ; but after that date they were ordered to be rolled up in 
blankets, and no linen was let touch the skin. In nearly every 
case the orders were strictly obeyed. 

Of 63, either bedded in sheets, or who had willfully thrown off 
their blankets, 6 contracted newly pericarditis at least, if not 
endocarditis as well; 3 had relapses of pericarditis on old cardiac 
lesions ; 1 had endocarditis alone ; on the whole 10, or nearly 
16 per cent., had inflammation of the heart, and 4 died. 

Of 184 in blankets, none have contracted newly pericarditis ; 
none have died ; 1 had a relapse of pericarditis on old cardiac 
lesions ; 5 had endocarditis alone ; 1 a relapse of endocarditis 
on old cardiac lesion. 



178 RHEUMATIC FEVER. 

One of these included cases of pericarditis was brought on 
during convalescence by the patient being dowsed with cold 
Water for an accidental hysteric fit. 

Not 4 per cent, have had any acute affection of the heart ; 
when it came it was of a milder character, and was generally to 
be accounted for by some imprudent exposure. 

That is to say, that bedding in blankets reduces from 16 to 4, 
or by a good three-quarters, the risk of inflammation of the heart 
run by patients in rheumatic fever, diminishes the intensity of 
the inflammation when it does occur, and diminishes still further 
the danger of death by that or any other lesion ; and at the same 
time it does not protract the convalescence. 



LECTURE XIV. 

GONORRHOEAE RHEUMATISM. 

Case. — Name of disease not strictly correct — Its relation to 
pyaemia — May occur at any period of the gonorrhoea — Not a 
metastasis — Objection to any treatment grounded on its being 
a metastasis — Urethritis a worse disease than gonorrhoea — 
Possible peculiarity of gonorrhoea! virus in these cases — 
Rarity of such severe cases as this shown by the results of 
seventeen other cases, which represent the more usual aspects 
of the disease — Specimen of a more usual case of gonorrhoea! 
rheumatism, and its treatment — Recurrence of gonorrhoea! 
rheumatism. 

{Clinical, St. Mary's, May 30, 1863.) 

Mrs. W — , aged twenty-six, exhibited, on February 12, 
symptoms resembling to my eyes those of a first attack of acute 
synovial rheumatism. She had been seized three days before 
with pains in the joints, and the right knee and left elbow were 
much swollen, and showed a slight erythematous blush of red- 
ness. There was headache and thir st ; the pulse was 112, and 
the tongue white and furry. The case so strongly resembled 
one of rheumatic fever, and so little one of gonorrheal rheuma- 
tism, and moreover the latter is so rare in the female sex, that I 
felt no hesitation about the diagnosis, and put her on the 
alkaline treatment for the disease I thought it was, with the 
addition of a few leeches to the affected joints. This went on 
till the third week in March, when the extreme obstinacy of the 
painful swelling, and its fixture in particular joints, induced me 
to make a more particular examination of the case with a view 



180 GONORRHEAL RHEUMATISM. 

to a revision of my diagnosis. She then confessed the follow- 
ing sad tale : — Three years previously she had been infected by 
her husband with syphilis, and bore a diseased dead child. 
Again she became pregnant, having in the mean time had second- 
ary sore-throat and a cutaneous eruption. The second child was 
born at seven months, and lived but a few hours. It also had 
an eruption on its body. She said she was again pregnant with 
a third, and was anxiously fearing for its life too, as she had 
then a purulent discharge contracted from her worthless husband. 
Curiously enough, he was stated by her to be also suffering from 
what she called "rheumatic gout," that is to say, a disorganizing 
inflammation of the joints, which had followed his gonorrhoea.* 
It was satisfactory to hear of the punishment of the guilty as 
well as of the innocent. 

I then changed the treatment, leeched freely, and blistered 
the principal joints, applied constant poultices, and gave her 
iodide of potassium to the amount of thirty grains a day. In 
the chronic state which the complaint had assumed, the blisters 
(according to the patient's statement) gave more relief to the 
pain than leeches, and the result of this treatment was to reduce 
the size of the joints by the absorption of synovia, and to relieve 
the patient much. But I am sorry to say the right knee and left 
elbow appear to me too much disorganized for any likelihood of 
her ever entirely recovering the free use of them. 

On May 26, she was confined of a healthy child at the full 
term, so that it must have been begot at the end of September 
last year. At that time she is sure that her husband had no 
complaint of any kind, and that he did not have the gonorrhoeal 
discharge I have spoken of till the middle of December. This 
accounts for the germ of the infant being healthy; and it is an 
encouraging circumstance to find' the filtration (if I may so 
speak) of the mother's blood through the placenta purified it of 
the poison which began to work in her system afterward, when 
her baby's ante-natal life was advanced to about four and a half 

* I afterward found this man in Middlesex Hospital, under the eare of Dr. 
Stewart. This case was entered in the case-book as oue of gonorrhoeal rheu- 
matism, and it seems he had had several previous attacks of the same nature. 



GONORRHEAL RHEUMATISM. 181 

months. It is valuable also to know that the thirty grains of 
iodide of potassium, which she took daily for ten weeks, and left 
off only when in labor, has no bad effect on utero-gestation, 
and may be safely given to breeding women. 

You have seen her to-day fulfilling the maternal duty of suck- 
ling her healthy infant. 

During the last fortnight of pregnancy there was a singular 
firm elastic tumefaction in the vastus externus of the right thigh. 
It felt like very soft India-rubber, was painless, distinct, and as 
big as a large orange. What it was I do not know, and it has 
now disappeared almost entirely. I do not think it had any 
connection with those remarkable swellings in the muscles which 
we find in syphilitic patients, because these do not vanish so 
quickly, being much more permanent. 

Before I proceed to comment upon the disease which has been 
the special object of treatment in this case, I would remark upon 
the healthiness of her present child. Such cases are a strong 
negative reply to a doctrine which is very popular, as to the 
irremovability of the syphilitic virus. I mean the doctrine which 
maintains that when it has once gained a firm hold of the con- 
stitution, it is always transmitted to all future progeny. Here 
you have convincing evidence of the constitutional affection in 
the deaths of the two first fruits of the womb, and evidence of 
its eradication in the health of the third. 

Gonorrhceal rheumatism is a convenient conventional term 
which we continue to employ, really for want of a better. It 
means a specific acute or subacute inflammation of joints and 
the neighboring white tissues, bearing in its external aspect a 
resemblance to sometimes one and sometimes another of the 
forms of the disease it is named after. But it has not the 
slightest other relation, either pathological or therapeutical, be- 
sides external similarity, to rheumatism. 

It is really due to a poison absorbed into the blood from a 
mucous membrane affected with purulent gonorrhoea, and thus 
has more claim to be classed by the side of pyemia than in the 
position where it is now placed. Like pyaemia, too, it has a 
strong tendency to disorganization of the affected part ; pus and 



182 GONORRHEAL RHEUMATISM. 

fibrin are formed, and the tissues are destroyed in bad cases. 
Like pyaemia, too, it does not exhaust itself by the inflamma- 
tions which arise ; it is not an acute disease, in the sense of tend- 
ing to recovery, but a chronic disease, getting worse and worse 
if not arrested. It is an accident of gonorrhoea, not an essential 
part of it, just as pyaemia is an accident of surgical operations 
on wounds. 

Its extreme rarity in the female sex is an additional evidence 
in favor of the poison being absorbed from the locally diseased 
part. In woman the mucous membrane principally aifected by 
gonorrhoea is the vaginal, a tough, strong surface which bears a 
great deal of ill treatment without serious injury. Its diseases 
have but little influence on the general health. But the male 
urethra is a much more delicate part, and we can easily com- 
prehend that it should oftener take up the gonorrhoeal virus and 
communicate it to the rest of the body. 

Being an accident, it may occur at any period of the gonor- 
rhoea, sometimes happening only a few cfays after the first com- 
mencement of the running ; but by the simple doctrine of chances 
of course more likely in the longer period before the patient is 
free. Hence it often appears just as the urethra or vagina is 
getting well, and so has been reckoned an instance of metastasis. 
Metastasis however it is not, for often and often the discharge 
continues as bad as ever, or even grows worse, while the joints 
are swollen. And when the joints get better, there is no return 
or aggravation of the original ailment. 

This is not merely a pathological question; for on the notion 
of metastasis it has been proposed to try and bring back the 
gonorrhoea to the genital organs by irritating injections. I have 
seen this actually done, but without any of the desired effect on 
the arthritic affection. Even if it were a curative operation I 
should be averse from practicing it, for the disease which you 
thus give the patient is not true gonorrhoea, but urethritis or 
vaginitis, and that of a chronic character — a much worse thing. 
I say it is a much worse thing, because it is so dangerous, so 
very difficult of cure, not rarely indeed proving quite incurable. 



GONORRHEAL RHEUMATISM. 183 

I published in the "Lancet." two years ago,* the case of a young 
man who died of inflammation of the bladder, caused by the ma- 
nipulations of a sperm atorrhoeist on his urethra, and I contrasted 
there the violence of the disease artificially produced with the 
mildness of a real specific gonorrhoea virulenta left to nature. A 
clergyman sometimes consults me about his general health, who 
has had purulent urethritis for the last three years, for which he 
has been to several of the principal surgeons in London, and 
tried all sorts of local remedies without relief; so that he has 
now made up his mind to bear it with patience and try no more. 
It was first caused by a too zealous practitioner having passed a 
catheter to ascertain whether certain nervous urethric symptoms 
were due to stricture. It was at one time suggested that the 
catheter might have been an infected one, but the absence of any 
specific virus was proved by his wife not contracting gonorrhoea, 
though he had not foregone matrimonial intercourse. It is a 
simple urethritis, just such as we should cause by local irritants ; 
and I think, with such cases before my eyes, I am quite justified 
in deeming urethritis a worse thing than gonorrhoea, and in de- 
clining to use it as a means of cure. 

To return to the patient now under our observation. She will 
tell you that there has been nothing like a metastasis to other 
parts of her body; the purulent discharge continued quite un- 
affected by the swelling of the joints, and she says the same is 
true of her husband also. 

It is a very singular thing that the gonorrhoea in both hus- 
band and wife should have been followed by the articular affec- 
tion ; it looks as if there was something special in the form of 
the original disease. But such an occurrence is quite excep- 
tional, and may be a mere coincidence. Indeed, my only reason 
for mentioning it, is to warn you of its rarity, in order that you 
may not put it down in your pathological sketch of gonorrhceal 
rheumatism. 

I must also warn you of the rarity of such severe consequences 

* Viz., June 15, 1861, in a clinical lecture. given at St. Mary's, but not repub- 
lished in this volume, as it has no special bearing on therapeutics or on the 
Renewal of Life. 



184 GOfrORRHCEAL RHEUMATISM. 

of gonorrhoeal rheumatism as these which you see before you 
now. In the great majority of instances, especially if they are 
treated early and actively, complete recovery results. I have 
not had an opportunity of bringing such a case before my present 
class, because there has not been, one under my care lately ; so I 
will extract a few examples from my old case-books. 

William M. (No. in Hospital Register, 2801), aged twenty- 
two, admitted November 26, 1853, had pain in one hip, with 
swelling and redness of the feet and ankles. He got no better 
for treatment with niter and warm-baths ; and then it was found 
that he had a gonorrhoeal discharge, and confessed that he had 
had a similar sort of rheumatism with gonorrhoea three years 
previously. He was cupped several times on the affected joints, 
and got well. 

Thomas J. (No. in Reg. 4119), aged forty, admitted October 
27, 1854, had contracted gonorrhoea, and got cold in a hay-field 
in August, and had had pains and swellings of the joints ever 
since. He had, on admission, swellings of the right wrist, and was 
helpless from pain in the knees, though those latter joints were 
not apparently enlarged. He got better in six days, with 
warmth, niter, and colchicum, and was dismissed. 

James C. (No. in Reg. 4202), aged twenty-six, was admitted 
November 17, 1854. Five years previously this man had con- 
tracted what he called "venereal disease," accompanied by an 
urethral discharge. Immediately afterward his knees became 
swollen and painful, and had remained so ever since, in spite of 
blistering. On admission, the right knee measured in circum- 
ference 17 inches, the left 13J- inches. The right elbow was 
also enlarged and stiff. The jaw-joint had been similarly 
affected, and he could open his mouth but a very little way. 
The orifice of the urethra was red, and itched a good deal, but 
there was no gleet. Colchicum internally, and iodide of mer- 
cury ointment to the joints did him no good. He was then 
treated with leeches, iodide of potassium, and copaiba. The 
pains were relieved, and the circumference of the largest joint 
was reduced to 15J inches by the second week in March. He 



GONORRHEAL RHEUMATISM. 185 

had then been in the hospital more than four months, and, as 
he considered himself able to work, I dismissed him. 

David 0. (No. in Keg. 5117), aged thirty-eight, was admitted 
July 10, 1855. After infection by gonorrhoea three weeks pre- 
viously, pain and swelling of the left knee, and pain at the side 
of the head, had come on. There was a good deal of fluid in 
the synovial sac, and he thought it was increasing. The urethral 
discharge was irregular, sometimes absent, sometimes present. 
He was ordered, for about ten days, three grains of calomel 
every night, and a senna and a jalap draught in the morning, 
and leeches were applied to the knee every other night for four 
times, and a weak chloride of zinc injection. The discharge and 
rheumatism ceased together, and he went out well in forty-five 
days. 

James K. (No. in Reg. 7717), aged twenty-four, was admitted 
April 17, 1857, with pain and swelling of several joints, accom- 
panied by redness of one wrist. He was treated at first with 
alkalies as for acute rheumatism. Then sclerotitis was observed 
in one eye, and, on examination, he was found to have a purulent 
discharge from the urethra, which he had hitherto concealed. 
He was leeched round the eye and joints, and both got well at 
the same time that the urethra ceased to secrete pus. He was 
in the hospital thirty-three days. 

William B. (No. in Reg. 8290), aged twenty-one, admitted 
August 21, 1857, at Whitsuntide had become infected with gon- 
orrhoea, which had continued ever since. At the beginning of 
July his ankles and one wrist got painful and swollen. They 
were not red on admission, though he stated that they had been 
so previously. For the first day he was treated with bicarbonate 
of potash, but, on the history being made out, it was left off. 
The treatment was changed ; he was bled once and leeched twice, 
and took copaiba, with some relief. Then he was packed for an 
hour a day in a wet sheet, but experienced no advantage at all 
from it. Then he took forty-five grains of iodide of potassium 
in decoction of bark daily, and went out cured on the 30th of 
October. 

Frederick M. (No. in Reg. 497), aged twenty-six, a butcher, 
13 



186 GONORRHEAL RHEUMATISM. 

caught gonorrhoea in the beginning of July, 1858, and was an 
out-patient of this hospital for it, not having any bad symptom 
to require his admission. The discharge ceased, apparently in 
consequence of treatment, and, about the same time, he began 
to suffer from pain in the knees and ankles. They soon swelled, 
and, on his admission, on August 19, were slightly red. His 
feet and ankles were freely leeched, and he had senna every 
morning. As the pains relaxed, iodide of potassium was alpo 
given. He was discharged as cured in twenty-four days, but he 
was admitted again under Dr. Alderson in November, and re- 
ceived benefit from colchicum. 

Cornelius W. (No. in Reg. 581), aged twenty-five, was admitted 
September 24, 1858, with pains in the hands and feet, moving 
about in those affected parts, but not attacking the larger joints. 
The patient presented at first the appearance of slight subacute 
rheumatism, but, as it came out that he had gonorrhoea, he was 
treated with iodide of potassium, purgatives every morning and 
hot baths. He began to get better immediately, and left the 
hospital in ten days. 

William M. (No. in Reg. 359), aged twenty-eight, admitted 
Midsummer-day, 1859, stated that three years previously he had 
suffered from gonorrhoea, which had been accompanied by severe 
pain and swelling of the knees. At the beginning of the current 
month he had again contracted the same complaint, and the 
knees and feet swelled and became painful. On admission there 
was still a running from the urethra, and the swollen ankles had 
a slight blush of redness. He was treated with leeches, purga- 
tives, and iodide of potassium. He left the hospital nearly well 
in a fortnight. 

Mary Ann M. (No. in Reg. 84), aged twenty-nine, was admitted 
February 10, 1860, and treated as a case of subacute rheumatism. 
She went out disappointed of relief on the 16th of the next 
month. It appeared she had, a few weeks previous to admission, 
contracted gonorrhoea, and that very possibly was the cause of 
the obstinacy of her symptoms, especially as she was not treated 
accordingly. I extract the case mainly as a possible example of 
gonorrhoeal rheumatism in the female, not leading to disorgani- 



GONORRHEAL RHEUMATISM. 187 

zation of the joints, as has happened to the patient whose history 
began this lecture. 

Henry P. (No. in Reg. 91), aged twenty-three, was admitted 
February 10, 1860. Eighteen months previously a purulent 
urethral discharge (which had continued for nearly two years) 
ceased, and about the same time he began to be affected with 
pains in the knees and feet, which got so tender he could not 
stand upon them. The feet were thoroughly well leeched three 
times, he was purged and took iodide of potassium, and in three 
weeks was well enough to return to his work as a painter. 

James B. (No. in Reg. 758), a smith, aged twenty-eight, had 
contracted gonorrhoea virulenta two years previously, but the 
purulent discharge frequently returned, and had never quite 
ceased. He had, on admission, pain and a collection of synovia 
in the knee-joints, for which he had been from time to time 
under treatment during the last year and a half at his native 
place, Hastings, but without benefit. He was admitted into St. 
Mary's, Nov. 9, 1860, was leeched three times, and had iodide 
of potassium so as completely to restore his health, at all events 
for the time, and left well Dec. 3. 

Henry L. (No. in Reg. 34), a gardener, aged thirty-nine, was 
under my care for four months at the end of 1859, for what I 
considered and treated as chronic gout. On his readmission in 
January, 1 861, he confessed to his former and present attack being 
consequent upon " a gleet." What he complained of principally 
was excessive heat and tenderness of the heels, soles, and toe- 
balls of both feet. They got red and swollen when he walked 
upon them, and quite prevented his following his occupation. 
He took iodide of potassium, was bled once, and was leeched 
twice on the feet. In about a fortnight he was freed from the 
ailment for which he came to the hospital, but unfortunately 
some of the leech-bites suppurated and sloughed, and he had to 
take bark and remain in till the 15th of March. That, however, 
was not so long as he had been under treatment inappropriate to 
his disease on a previous occasion. 

William B. (No. in Reg. 362), aged twenty-five, was admitted 
May 18, 1861, with buboes in the groin, accompanied by a puru- 



188 GONOKRHCEAL RHEUMATISM. 

lent urethral discharge of five weeks' duration. His knees and 
ankles had become swelled and painful, for which he came under 
my care. He was at first treated with alkalies for subacute 
rheumatism, and was reported better ; but on getting up his 
pains immediately returned again, and he was put upon iodide 
of potassium, which quickly cured him. He left the hospital 
June 14. 

Henry P. (No. in Reg. 847), aged twenty-three, was admitted 
August 9, 1861. Five years previously he had had gonorrhoea, 
which got well without any bad symptoms. A month before 
admission he was attacked with pains in the ankles, knees, hips, 
and right elbow. He then found he had a purulent inflammation 
of the urethra, with a scalding on making water. On examination 
the feet and knees were found swollen, and there were some 
superficial excoriations on the glans penis, attributed by the 
patient to the collection of discharge, which the stiffness of his 
joints prevented him from cleaning away. (This seems to show 
the peculiar acrimony of the virus in these cases, for ordinary 
gonorrhoea! pus does not excoriate the skin.) This patient had 
also gonorrhoeal ophthalmia. He was leeched and took iodide 
of potassium, and went out well September 6. It may be re- 
marked, in passing, that his leech-bites also inflamed, like Henry 
L.'s, but whether that is the fault of the leeches or of the 
patients, I cannot say. 

John B. (No. in Reg. 66), admitted January 24, 1862, had 
had a chronic purulent discharge from the urethra for a year, but 
had experienced no further inconvenience from it till January 
20, when he was taken with rigors and aching in all his limbs. 
Then his joints swelled. He was cupped, leeched, and purged, 
and had blisters applied to his knees, and took internally copaiba 
and cubebs. He went out well on the 21st of March. 

(Clinical, St. Marys, November 14, 1863.) 

James M., aged forty-six, a butler, caught gonorrhoea three 
months ago ; and six weeks ago, as the urethral discharge was 
ceasing, pains commenced in the elbows, ankles, and knees. 
These pains were fixed, not metastatic, and grew worse and worse 



GONORRHOEAE RHEUMATISM. 189 

in spite of treatment. The left knee swelled more and more, and 
at his admission on November 7, there was a considerable accu- 
mulation of synovia in the joint. His general health was good, 
his appetite large ; the bowels, pulse, and skin were normal. I 
kept him in bed, starved him, leeched twice, and steadily fomented 
the enlarged knee, gave him a scruple of iodide of potassium 
daily. Under this treatment for a week, the swelling has quite, 
and the pain nearly, disappeared from the knee ; the other joints 
feel quite well. He cannot, however, straighten the leg, the 
tendons of the ham being impeded in their action by having con- 
tracted partial adhesions to the surrounding parts. I expect the 
slight pain that remains will be somewhat obstinate, and that we 
shall have to leech the knee a good many times before it disap- 
pears.* If the contraction remains after that, mechanical means 
to free the tendons may be employed. 

I detail this case to you as a specimen of the more usual, or 
mild form of gonorrhoeal rheumatism. If left alone and allowed 
to be ingrained into the constitution it becomes very obstinate of 
cure, and doubtless would have done so in this instance, unless 
the patient had been submitted to active treatment at this early 
stage. Now you see it is more manageable, but still by no means 
so easy of cure as ordinary rheumatism or gout. 

As to the rationale of the treatment. The reason for its 
adoption is experience of its good effects, the little effect which 
other treatment has, and the certainty that the tendency of the 
disease is to get worse and worse if left alone. My conjectural 
explanation of its action is as follows : I suspect the cause of the 
disease to be a virus especially fatal to the vital functions of the 
white non-vascular tissues, which is carried to them from the 
urethra by the blood. The partial loss of vitality in these white 
tissues causes congestion and inflammation in the neighboring 
capillaries,f with pains and extra-vascular accumulations of 

* He was leeched eleven times before he left the hospital for Christmas day, 
having found that nothing did so much good as that treatment. His leg w.as 
not quite straight even then, and I cannot say that the last four leechings were 
of any use. 

f See " Lister on the early stages of inflammation." Philosophical Transac- 
tions of Royal Society, Part II for 1858. 



100 GONORRHEAL RHEUMATISM. 

serum. The leeching and fomentations act upon the inflamma- 
tion, and the iodide of potassium directly as a restorative to the 
white tissues ; as to the starving, I do not know what to say — 
perhaps it does good by promoting absorption — perhaps it is not 
so requisite as we suppose. 



(Clinical, St. Marys, February 6, 1864.) 

The sequence of rheumatism after gonorrhoea seems to depend 
more upon the diathesis of the individual attacked than upon any 
peculiarity of the infecting virus ; for, while some have the 
urethral part of the affection over and over again and suffer no 
further, there are others who never contract the slightest puru- 
lent discharge without the limbs being afterward crippled. 
This is illustrated by a man who was admitted on the 2d instant, 
Henry P., aged twenty-seven. He was under my care here in 1860 
for gonorrhoeal rheumatism, and went out in three weeks quite cured 
by leeches, poultices, rest, and iodide of potassium.* He seems 
to think himself exceptionally virtuous and lucky in having not 
again caught gonorrhoea till last August, and unlucky in its being 
followed in five weeks by painful swellings in his two ankles and 
one knee, which have continued to get worse. You heard me, 
in rebuking him for his nauseous vice of fornication, threaten 
him that each time he contracted gonorrhoea it would certainly 
. be followed by this painful consequence ; and I believe that I 
was not at all exaggerating, when I stated that possibly it might 
in the end cripple him for life, for I have seen instances of its 
really doing so. I shall this time put him under the same treat- 
ment as before, with probably the same result ; but I feel strongly 
disposed to reject him as a patient, for having a second attack 
after he had once received such a warning of the consequences 
of vice. I think the threat of rejecting him will have an in- 
fluence, for though he has been under medical treatment four 
months, he has got no better and feels the need of the leeching, 
poulticing, starving, and vigorous nursing which he will now 
receive. 

* The case is catalogued in page 187 (No. in Reg. 91). 



LECTURE XV. 

PERICARDITIS. 

Case of pericarditis coming on in the hospital — Rarity of this cir- 
cumstance — Explanation of its occurrence in this instance — 
Diagnosis of old and recent disease by the physical signs — 
Practical value of diagnosis — Treatment — Leeches — Blisters 
— Poultices — Prevention better than cure — Case illustrative 
of the use of mercury in similar circumstances , and the 
reason why it is no longer employed by the author — Fatal 
case of pericarditis from exposure to the cold during conva- 
lescence from typh-fever — Two cases of pericarditis, one 
arising from a linen shirt-front next the skin during rheu- 
matic fever, the other of doubtful origin — Action of opium 
on the pulse — Variations in the pulse — Remarks on the pain 
of pericarditis — Case illustrating its absence, and the non- 
reduction of the pulse by opium — Fatal pericarditis in a 
patient of choreic diathesis. 

{Clinical, St. Marys, June 21, 1862.) 

You may see an example of pericarditis which has come on in 
the hospital in a little girl named Fanny R — , admitted May 
31. She has always been delicate, she says, and looks younger 
than seventeen, which is entered as her age. She has never spat 
blood, but often has had cough, and for the last three months 
of 1860 was in the Consumption Hospital. Also eight years ago 
she went through rheumatic fever. On admission she said she 
had been then ill four days, and that she had been attacked with 
rigors and with pains and swellings in the knees and wrists at 
first. However, nothing of the sort was to be found on examina- 



192 PERICAEDITIS. 

tion ; but dullness on percussion, with segophony and absence of 
breath sounds, showed the presence of pleuritic fluid, though 
there was but the slightest possible evidence of any acute inflam- 
mation of the serous membrane in the presence of stitch on 
inspiration. In spite of her being an intelligent girl, she seems 
peculiarly insensitive to pain. She was treated with a poultice 
first, and then a blister on the side, and " teacup" diet of beef- 
tea and milk. It was on the night of the 4th that the blister 
was put on. She was going on very well, improving in strength 
and in power of inspiration, till the morning of the 7th instant, 
when she complained of pains in the hands and wrists, which on 
inquiry were found swollen, as if from rheumatic inflammation. 

She strongly denied having any pain in the cardiac region, 
even on firm pressure ; so that, had I not been aware of her degree 
of insensibility to pain, I should have concluded at once that 
the heart was free from lesion. Fortunately I was cautious, and 
on listening with the stethoscope, a loud murmur was heard with 
the first sound of the heart, loudest indeed at the center of the 
organ, but propagated over the upper part of the chest. Take 
warning from this, and do not omit to consider whether your 
patients feel like other people or not before you let your diag- 
nosis be guided by their feelings. 

With regard to this murmur, there arose a question of diag- 
nosis, very important as regards treatment. Did it denote an 
old incurable injury derived from the former attack of rheuma- 
tism, or was it an acute state admitting of restoration ? In the 
first place, there was in favor of its being an old valvular mrumur 
the fact of the previous rheumatism, and the peculiar liability 
of children, even more than adults, to have the heart affected : 
then there was its single character (pericardial murmurs being 
usually double) and the entire absence of pain. To weigh 
against the latter argument might be urged the already-named 
stoical character of the patient ; and in favor of the recent nature 
of the injury there was stated the fact that nobody had heard it 
before, though the chest had been examined in reference to the 
lungs. But on the other hand, it should be remembered how 
very apt the ear is to let pass unheard even a loud sound when 



PERICARDITIS. 193 

the attention is directed elsewhere. So you see there was an 
awkwardly even balance of arguments. 

In this dilemma I found the advantage of what I can recom- 
mend to you as by far the best extant means of distinguishing 
single pericardial and valvular murmurs — sounds precisely the 
same in their effect on the ear, and occurring often at the same 
period of the cardiac movements, and therefore undistinguish- 
able unless particular manipulation be used. The plan is — first 
fit the stethoscope firmly and steadily on the place where the 
murmur is loudest, and get impressed on the auditory nerve 
clearly the special character of the murmur ; then, keeping the 
instrument still closely applied to the chest in the same position, 
remove your head very gradually, and try to gain a point at 
which you can hear the normal heart sounds without the mur- 
mur. If you can do this, the murmur is pericardial. If you 
cannot, "but the murmur is heard as far off as the heart sounds, 
it is endocardial. In all cases where the disease is endocardial 
only, or pericardial only, the knowledge thus obtained may be 
safely acted upon. 

I acted upon it in this instance^ in spite of a prepossession 
derived from the history and from the absence of pain, that it 
was an old valvular injury which gave rise to the symptom. In 
three days' time the conclusion was proved correct by the mur- 
mur becoming a double rubbing with the familiar characters of 
pericarditis. 

I had enough faith in the test to order directly four leeches 
over the cardiac region, followed by a half-jacket poultice, and 
to attend to the more important serous membrane now inflamed 
instead of attending to the pleura. The patient was also put 
upon the usual treatment for rheumatic fever which I have 
detailed in previous lectures. After four days the double rub- 
bing got shorter in duration and more limited in the extent 
over which it was heard, and then I ordered a small blister over 
the base of the heart. The rheumatic swelling had left the 
hands, so the alkaline treatment was then left off, but the poul- 
tice was continued. 

I have related these details to impress upon you the plan to 



194 PERICARDITIS. 

be pursued in rheumatic pericarditis from whatever cause it has 
been unhappily induced. Had the painful swelling of the hands 
in this poor broken-down child preceded by a sufficient interval 
the inflammation of the heart, we should have had a timely 
warning, and possibly the useful careful treatment pursued by 
our nurses would have prevented the misfortune. But the 
occurrence of both at once, and the unlucky neighborhood of 
the already diseased lung, combined to inflict upon us the sad 
sight of an irremedial mischief in process of formation. I say 
an irremedial mischief, because it cannot be doubted that this 
adherent pericardium will cause her to suffer from the evils of 
diseased heart in future years. 

One part of the treatment which particularly wants remark 
is the application of blisters. At the beginning of acute serous 
inflammation they unquestionably do much harm. They increase 
its heat and violence, and all the more the nearer they are to 
the part affected. The action of the cantharides is to cause a 
fibrinous serum instead of a plain serum to be thrown out, which 
is a result decidedly to be deprecated at the beginning. But at 
a later stage, when pus is our chief dread and not fibrin, then 
the virtues of cantharides come to our aid. At this conjuncture 
apply your blister, and apply it as close as you can to the 
affected part ; the healing process which follows its action on the 
healthy tissue spreads by continuity to the diseased tissue, and 
you feel yourself powerfully aiding the forces of life. 

You should keep a poultice on the cardiac region during the 
whole time that pericarditis lasts. Nothing is of more import- 
ance in the treatment. Neither leeches nor blisters need stand 
in the way of its application ; it is of at least equal importance 
to either of them in restorative action, and is suitable for all 
stages of the disease. 

(Clinical, St. Marys, July 5, 1862.) 

Fanny R., whose case I lectured about a fortnight ago, has 
got into a state to justify her discharge from the hospital in a 
few days. The pulmonary regions have become resonant on 



. PERICARDITIS. 195 

percussion, though some crackling (rdle de retour) accompanies 
the air returning to the scarce restored tissues of the left lower 
lobe. The opposite sides of the pericardium may be adherent at 
some points, and the adhesions impede the contraction of the 
heart, I much fear ; for there is a soft initial murmur with the 
systole heard as far off as the first sound can be heard, caused 
probably by the valve not clinching completely and so allowing 
of regurgitation. 

The pericardium can hardly help becoming adherent after its 
inflammation, and the moral I would draw from this case is to 
think the prevention of the injury, when threatened, a thousand- 
fold more important than its treatment, when established. I 
told you, six weeks ago, in a lecture on rheumatic fever, how 
this prevention is to be aimed at, and how it may generally be 
accomplished.* 

I do not order mercury in acute pericarditis, and I will frankly 
tell you why, since it is right that I should make my practice 
useful to you as a warning as well as an encouragement. Ten 
years since a robust and excitable girl of sixteen had rheumatic 
fever ; from her constitution I feared she was likely to have her 
heart affected, for young persons of a nervous temperament are 
much the most liable. I had then an impression that mercury 
would prevent the occurrence of inflammation in serous sacs. 
I put her under the influence of mercury — the pericarditis came 
on, and in its most virulent form — and the patient died in the 
height of it. This result made a deep impression on my mem- 
ory ; her fair young face always rises before me when the idea 
is mooted of preventing pericarditis with mercury, and I shrink 
from using it. Of course, to the reason a single case does not 
prove so much as statistics of many, and I do not cite this as 
sufficient evidence to your minds against the use of mercury. 
But it gained a powerful hold on my imagination, and if prac- 
titioners would be honest to themselves, they would often confess 
that some such feminine evidence as that above quoted governs 
a good deal of their practice. If I am illogical in my reason, at 
all events I will be manly enough to confess it. 

* See page 157. 



196 PERICARDITIS. 



(Clinical, St. Mary's, February 20, 1863.) 

I have an unfortunate occurrence to relate to-day. The poor 
girl, Elizabeth J., about whom I lectured to you three weeks 
ago,*, and whom I described as then recovering from a short 
attack of typh-fever caught in the hospital during convalescence 
from acute rheumatism, has since died. She went on very well, 
and had began to eat meat and to be up and dressed on the out- 
side of her bed, when she was exposed to severe cold from the 
ward windows being all opened during the frosty days we had 
last week. This brought on an attack of pericarditis on the 
14th, of which she died on the 16th. I show you here the peri- 
cardium honeycombed over with fresh lymph. But I doubt if 
it was her first attack of pericarditis. On admission she stated 
that she had been previously subject to rheumatism, and during 
the attack for which she was admitted there was one day pain 
on pressure on the cardiac region, sufficient to make me order 
leeches to be applied, although there was no murmur. I think 
it is to some former attack probably that the firmer of the 
adhesions are due. 

I mention this case mainly to warn you against exposing to 
the assaults of cold persons of rheumatic diathesis. All this 
injudicious ventilation which caused our patient's death was 
practiced for the safety of others. Because she had typh-fever 
she was placed between two open windows, and continued to 
occupy the bed after all risk of infection had passed away. It 
was a sad misadventure, but you must not attribute her death to 
fever, or your statistical calculations will be erroneous. 

(Clinical, St. Mary's, January 9, 1864.) 

You have visited with me to-day two examples of pericarditis, 
which are worth notice. 

George D. is a pale spare man of unhealthy aspect, a car- 
penter, aged nineteen, who was admitted December 22 for rheu- 

* See page 142. 



PERICARDITIS. 197 

matic fever of nine days' duration, principally affecting the feet 
and knees. There was no bed for him except one close under a 
window, which, unfortunately, cannot be always kept shut. 
However, he was wrapped up close in blankets, and I dare say 
would have done very well, but for an important neglect of part 
of the usual treatment. You know I give strict orders that 
rheumatic fever patients are not to have any linen touch their 
skin. Well, on my visit to this man on the morrow of Christmas 
day, I found him with a pericarditis, of which I had made out 
the absence on his admission and on Christmas eve. And on 
putting aside the clothes for the purpose of auscultation, I found 
that the only covering to his bosom was cold, hard, damp linen. 
My rebuke to the ward-sister was met by the statement that 
she thought it was only a linen shirt that I objected to, and 
that the patient really had on one of calico. This I found to be 
true enough, but yet there was a linen front to it (for orna- 
mental purposes), and the front unfortunately covers just the 
most important part of the body, the cardiac region. I am sure 
we may safely attribute the occurrence of pericarditis to this 
chilly decoration. 

To avoid in future such an evasion of the standing orders for 
the treatment of rheumatism, I shall have a flannel waistcoat 
put next the skin of each person so affected. 

George D. has had his chest leeched and poulticed, and has 
taken opium freely, according to my usual practice, and the peri- 
carditis has run through the course it usually takes when not 
very severe. First there was pain and a murmur only occasion- 
ally double, whose frictional character was made evident only 
by collateral evidence ; then the murmur became faint and there 
was slightly increased dullness on percussion of the cardiac region, 
with pain still remaining, indicating an accumulation of fluid in 
the sac ; then a freedom from pain, accompanied by a double 
friction sound, indicating the absorption of the fluid. To-day, 
the fifteenth after the first assault of the pericarditis, the murmur 
is single and scarcely to be heard, the sounds being very soft and 
feeble. 

George D.'s strength had been much reduced by the rheumatic 



198 PERICARDITIS. * 

fever, prolonged as it was by the pericarditis, so that at the 
beginning of this week I found a slight sore from a superficial 
slough of the skin on the sacrum. Accordingly, I put him upon 
bark and ammonia, and augmented his diet to an extent unusual 
in rheumatic fever. To-day the sore is nearly healed, but the 
patient is so weak that he can scarcely turn in bed. 

The other case is that of Ann B., a fresh-colored, cherry- 
lipped girl, aged nineteen. When I came to admit patients 
yesterday, I found her in the waiting-room, throwing herself 
back in the chair, breathless and gasping, and plucking with her 
hands at the fore part of her dress as if she would tear it open. 
She said she was choked by violent pain in the front of her 
chest, cried out and whimpered, and was so exaggerated 
altogether in her manner that I felt doubtful if it would not 
turn out to be a case of hysteria. Yet her aspect was not that of 
an hysterical person, so I sent her to bed ; and being then able 
to examine the thorax, I found localized in the cardiac region 
excessive pain on pressure, and a distinct double friction sound. 
The breathing was very hurried, and the pulse 120, small and 
w T eak. 

When more composed, the history she gave was this: she has 
never had rheumatic fever or any other serious illness ; but for 
several winters past has had pain, of no great consequence, across 
the front of her chest. For the last three weeks she has felt 
unwell, but has not been laid up from w T ork till the 6th instant. 
Then this pain commenced, got rapidly worse on the 7th, and 
on the 8th (yesterday), as I have said, she came here. She can 
assign no cause for her illness, nor can anything be elicited by 
cross-examination to account for it. 

I ordered her a dozen leeches to the cardiac region, to be im- 
mediately followed up by a continuous linseed poultice, a grain 
and a half of opium every four hours, and "simple" diet. 

At our visit to-day you saw a great change in the twenty-four 
hours. The patient had not been made sleepy by the opium, but 
had been calmed in a remarkable degree. A numerical reckon- 
ing of the amount of calm was afforded by the pulse, which had 
sunk from 120 to 56, was firmer and stronger. This effect of 



PERICARDITIS. 199 

opium is very important in pericarditis, when quiet for the busy 
heart is so desirable and so difficult to procure. It is singular 
what a large quantity may be taken without hypnotism, or even 
constipation, in all serous inflammations. So that when time is 
of value, as in this case, you should begin with what cannot be 
called, under ordinary circumstances, imprudently large doses, 
or you will not have mounted up to the efficient quantity early 
enough to be of use. I have increased the quantity now to a 
grain and a half every three hours. 

Pressure on the cardiac region gives less pain to-day, and, 
the heart being quieter, the stethoscopic evidence of the disease 
is easier to make out. The to-and-fro friction sound is well 
marked. 

The patient says that at present her chiefest pain is caused by 
breathing deep and by swallowing. The first she can of course 
shun, and I dare say will do so. The second is to a certain 
extent unavoidable, but we will do our best to relieve her by 
giving only liquid food, and in very small quantities at a time. 

(Clinical, St. Mary's, January 23, 1864.) 

Ann B., about whose pericarditis I lectured to you lately, has 
interested us by the variations in her pulse. It continued slow 
till the 12th, when a visitor in the middle of the day appears to 
have engaged her in a conversation too long, and it rose, so that 
by night it was 120. She continued to take the opium (gr. iss 
every third hour), and on the 18th it dropped to 96, on the 14th 
to 86, on the 15th to 80, on the 16th to 76, on the 20th to 72, 
and on the 23d (to-day) it has risen again up to 88. This rise 
may be partly due to the patient's menstrual period, which has 
just commenced, making her sensitive and excitable, partly 
perhaps to a slight relapse of inflammatory action in the peri- 
cardium. 

The pericardium has, on the whole, progressed favorably; the 
friction sound continued double till the 13th, when it was found 
to be single only. It got less loud, and on the 20th one could 
hardly say there was a friction at all, though with the first sound 



200 PERICARDITIS. * 

of the heart there was a peculiar harsh tone. However, to-day 
I can distinctly detect a friction sound. 

The opium has agreed with her well. On the 16th it was 
increased to two grains every three hours, and it produced no 
abnormal sleepiness or constipation; nor has it prevented the 
return of her appetite, for on the 20th she was ordered a mutton- 
chop, on her own statement of feeling very hungry. To-day, the 
23d, I have increased the dose of opium to gr. iij every three 
hours during the catamenia. 

Of course we have been watching for any symptoms of rheu- 
matic fever; and on the 16th I thought that a pain she felt in 
one foot was an announcement of its approach; but that passed 
away quickly, and was accompanied by no redness or swelling. 

I am anxious to draw your attention to the more than ordi- 
nary pain which this young woman has experienced from her 
pericarditis. At first it was excruciating; and even on the 20th, 
when the friction murmur had ceased, firm pressure of the car- 
diac region made her wince. I especially wish you to notice it, 
because there is a case of pericarditis which was admitted nearly 
at the same time, where there is a remarkable absence of this 
symptom. 

John C, a journeyman butcher, aged twenty-four, was taken 
ill with rheumatic fever on the 10th instant. I saw him first on 
the 13th, when he complained energetically of the painfulness of 
the swollen joints, but disclaimed having any inconvenience in 
the chest ; nor till I pressed my stethoscope on the cardiac region 
really hard, would he allow that it hurt him. Notwithstanding 
which, when I applied the ear I found a loud double friction 
sound. The sounds grew coarser, but shorter, up to yesterday, 
the 22d, when I could no longer hear them, and conjectured that 
adhesion had taken place. 

I cannot explain why there is pain in one case more than in 
another; it certainly does not denote severer disease, because in 
all other respects the man was the worst of the two patients. 
Perhaps it may have something to do with the absence of 
rheumatism, the pain of which withdraws the attention of the 
sensation to the joints, or wherever the swellings and redness 
may be. 



PERICARDITIS. 201 

Attacks of non-rheumatic pericarditis are more common in 
private practice than in hospitals. They usually arise from sim- 
ilar causes to those which cause pleurisy, namely, exposure of 
the part to sudden chills while its vitality is lowered by previous 
exertion. I had a case this week arising from walking out into 
the night air after exertion at a dinner party ; and in boys foot- 
ball and boating are often to blame. 

The treatment of John C. was the same as that of Ann B. He 
was twice leeched, and is still enveloped in a linseed poultice. 
On the 13th, he was ordered gr. iss of opium every four hours; 
and on the 17th, as he was somewhat delirious, and the pulse 
was 120, gr. ij every three hours. The delirium then ceased, 
but the pulse kept up. On the 20th, gr. iij every three hours. 
On the 22d, he said he was certainly more drowsy than usual, but 
the bowels were not made costive by the opium. The pulse kept 
up to 120. As he was entirely free from rheumatic pains, I 
ordered the quantity of the drug to be diminished to gr. ij every 
three hours, which he is continuing to take. 

The extreme quickness and weakness of this man's pulse 
throughout has made me very anxious about him. The opium 
has seemed not to diminish it, as it did in Ann B., and that is 
the reason why I have' pronounced him the worst of the two. 

In John C. you have seen pericarditis in its most familiar 
aspect, that is to say, arising in the course of rheumatic fever, 
as a consequence of the exposure of the chest to cold, or the 
attempt at bodily exertion. In Ann B. there is no evidence of 
its connection at all with rheumatic fever. In the case I am 
going next to relate to you, there was no rheumatic fever present 
indeed when the pericardial inflammation came on, but there was 
a diathesis somewhat connected with the rheumatic, though in 
what way it is difficult to define.* 

***** 

Alfred M., a delicate and thin boy of ten, was admitted De- 
cember 18th ult. for chorea. He had had the same two years 
previously, and also at some periods, which he could not remem- 

* See the concluding part of Lecture XXIX, on Chorea. 
14 



202 PERICARDITIS. 

ber accurately, redness and swelling of the joints. On admis- 
sion, he said his feet were painful, but I could see nothing like 
rheumatic swelling. There was a loud rumbling, continuous 
murmur with the heart's action, which was violent and tum- 
bling. This I attributed, I cannot say how correctly, to lesions 
produced by old disease. The cardiac symptoms were better 
after the lad had been quiet in bed a few days and had had a few 
leeches on. He was then treated with arsenic for the chorea, 
and got better, so as to be playing about the ward with some 
other boys up to the morning of the 20th of January. On that 
morning he told the nurse he had a severe pain in the front of 
his chest; so she bade him lie in bed, and sent immediately for 
the house surgeon, Mr. Coombs. He found a loud double friction 
sound in the cardiac region, and immediately leeched and poul- 
ticed it ; but the lad got rapidly worse, and died in the evening 
of the same day. 

You see here the heart and pericardium. The visceral portion 
of the serous membrane is partially covered with grains of soft 
lymph, in some places formjng a reticulated coating : the parietal 
portion has a smaller quantity of the same lymph attached to it. 
Exposed parts of the serous membrane are (and were still more 
'when first taken out) deeply stained with a purplish red conges- 
tion. The sac was filled with five or six ounces of transparent 
serum. And in the adjoining pleura of the left side there was a 
larger quantity of similar fluid; but as they flowed together in 
opening the chest, I could not apportion the property of the re- 
spective cavities. The opposite surfaces of the pleura were 
joined by some delicate threads of very soft lymph. The other 
viscera were normal in aspect. 

The heart is large, weighing with the pericardium 10 J ounces. 
It has not been opened in the usual way, because I was anxious 
to show you the phenomena of pericarditis in its early period, 
the reddening of the membrane in the first stage of death, and 
the soft, almost creamy, coagula of lymph which produce friction 
sounds. But I can hardly doubt that there is old valvular lesion ; 
and to the old lesions I attribute the remarkable rapidity with 
which the patient sank under what I suppose may be called an 



PERICARDITIS. 203 

acute pericarditis, occurring without rheumatism to a rheumatic 
individual, and in_ a predisposed heart. The external motive 
cause I can only conjecture to be some secret escapade of the 
poor child's, which exposed him to cold and unauthorized exer- 
tion, and which he concealed from fear of a scolding. 

[A few days afterward John C. was able to get up, eat meat, and leave off 
opium. He was discharged cured on February 6. Ann B. had the quantity of 
opium gradually diminished to gr. j night and morning, which to-day (February 
10) she says makes her sleepy, so it is omitted altogether. There is no murmur 
audible in the cardiac region, but the first sound is very long. She is up and 
dressed.] 



LECTURE XVI. 
PLEURISY. 

First case, and its treatment — Oases of pure pleurisy not common 
in hospital practice — It is a slight disease, but capable of 
being made much more severe by bad management — Remarks 
on blisters and on local blood-letting — Their final intention 
restorative — Poultices — Continuous warmth as a renewer of 
life — Second case — Chronic effect of acute pleurisy — Treat- 
ment — Diuretics — Blisters — Third case—Pyeemic pleurisy, 
its fatality. 

[Clinical, St. Mary's, July 5, 1862.) 

I am glad to have an opportunity of bringing before you to- 
day an example of a disease so common in practice as to be one 
of serious import for you to study, but of which specimens do 
not very often occur in our hospital wards, — pleurisy uncompli- 
cated with further inflammation of the lung. 

Thomas G., a day laborer, aged twenty-nine, was warded June 
19, with anasarca of legs and belly of a fortnight's duration, 
which he attributed to exposure to the weather. His urine was 
found to be albuminous. The house surgeon gave him a hot-air 
bath, a jalap purge, and some draughts of nitric ether and digi- 
talis. When I visited him next day (June 20), he complained of 
sharp pain on both sides of the waist, which he said had been 
coming on for two days, and was getting worse. On auscultation 
I heard pleuritic friction beneath both scapulae and in the lateral 
regions ; the normal respiratory murmur was still to be made out 
in spite of it ; but there was a leathery creak, lasting through the 



PLEURISY. 205 

whole of respiration and the latter part of expiration. The 
tongue was furred, and there was thirst. 

He was ordered to be cupped, but as the instruments had un- 
luckily gone to he mended and would not be returned for an 
hour or two, a dozen leeches were applied along the lower edges 
of the ribs, in the infra-scapular region. Immediately they came 
off a large poultice was placed all over the back of the chest. 

The next day (June 21) the pain and fever were quite gone, 
the friction sound was heard over a limited space, and on the 
22d had departed altogether. The poultice was continued one 
more day, as the patient remained in the hospital to be treated 
for albuminuria. 

Patients with pure fibrinous inflammation of the pleura, 
usually called pleurisy, without any affection of the pulmonary 
tissue, you have as yet probably not often had a chance of 
seeing. But you know from your post-mortal experience in our 
mortuary how common it must be. There are few even of the 
most healthy chests in which you do not see old adhesions of 
the pleuritic surfaces, the relics of pleurisy, sometimes in one 
part, sometimes in another, sometimes partial, sometimes uni- 
versal ; they are so common, that they were supposed to be the 
normal condition of the parts when anatomy began first to be 
studied after the restoration of learning. What is the reason, 
then, that you have but few opportunities of learning how to 
treat this very common disease while you are pupils ? Simply 
because it is scarcely ever so severe as to bring the patient into 
our hospital wards, and is fatal only by very rare exception ; 
so that your only chance of observing it is when it is joined to 
some more alarming disorder. The man who is the occasion of 
these remarks would never have been admitted to St. Mary's 
had he not been taken dropsical at the same time as he caught 
his pleurisy. 

Nine times out of ten pure pleurisy begins and ends with a 
catching pain in the side on inspiration, and a slight inflam- 
matory fever, making the patient coddle at home and take slops, 
but not employ a doctor. It would be, perhaps, better for him 
if he did, for possibly his may be the hundredth or exceptional 



206 PLEUKISY. 

ease, and his illness may turn out a more serious affair. More- 
over, in every case, the pain in the side and the fever may be 
shortened by good management and lengthened by bad. 

For example — blisters at the outset of pleurisy invariably 
protract the duration of the inflammation and make it more 
severe. The property of cantharides is to cause and augment 
that very fibrinous crasis from which the membrane is already 
suffering. Exposure to cold and to changes of temperature, 
baths and the like, make it worse, a§ do strained postures of the 
body and exercise. Opiates cover up the evil with an anaes- 
thetic mask, and prevent the patient knowing how he really is. 
Mercury is an unnecessary call upon the whole system to make 
destructive sacrifices for the sake of a very small and not highly 
important member. Purgatives do no good, and expose the 
patient to catch cold at the water-closet. 

On the other hand, the treatment you saw applied gives 
decided and immediate relief, and prevents the danger of the 
disease continuing. 

It is necessary to remark that the whole of it was not meant 
for the benefit of the pleura ; the hot-air baths, the diaphoretic 
draughts, and the jalap were intended to rid the skin of ana- 
sarca, and were successful in so doing ; while the treatment to 
which I design to call your attention as that specially appro- 
priate to pleurisy is the application of the poultice and the 
leeches — the poultice always, and the leeches whenever the pain 
is decidedly u catching" or " stabbing" on inspiration. 

I will speak of the last first, as it is most open to exception. 

The object of leeching and all local blood-letting is to relieve 
inflammatory congestion, not only an evidence of loss of vital 
power in the local blood-vessels, but also the cause of further 
loss of vital power by leading, to the other stages of the inflam- 
matory state. The blood-vessels, from loss of elasticity, are 
unable to empty themselves naturally, so you roughly take the 
place of vital power and empty them artificially. You may 
perchance say, that it is all very well in external inflammation, 
when you can draw off the blood which is causing the "rubor" 
and " tumor " visible to the naked eye ; but you may doubt how 



PLEURISY. 207 

the pleura, especially the pulmonary pleura, is to be affected by 
depleting the capillaries of the skin. Your recent experience 
in the dissecting-room reminds you that it is a very long way 
round before you can find any vascular connection between the 
parts ; you may think local blood-letting only beneficial by de- 
tracting so much blood, and that a small venesection would be 
more convenient and equally effectual. Now it is not at all 
essential that there should be a vascular connection between 
separate parts for altered states and conditions of life to spread 
from one to another. I have seen in the dead body a round 
circumscribed spot of costal pleura affected with fibrinous in- 
flammation, and this had spread, not laterally to the neighboring 
surface of serous membrane, not to that tissue intimately one 
with it in vascular connection, but to the opposite surface on the 
lung, between which and its substance lay the great gulf of the 
pleural cavity — the great gulf, anatomically speaking, but not 
•physiologically, as proved by this instance. If this gulf can be 
spanned by disease, the negation, the deficiency of life, shall it 
not be yet easier stepped across by the remedy, the renewer of 
life ? I do not myself feel any hesitation in believing firmly 
what experience seems to teach, that in inflammations of serous 
sacs, depletion applied to the external surface has a power pro- 
portionate, not alone to the quantity of blood taken, but in an 
equal degree to the locality from which it is taken. 

I have called the local drawing of blood a " renewer of life," 
and I think it is but fair to explain in what sense I so speak of 
it. The taking away the vital fluid is taking away part of the 
body, and so is directly a destructive agent. But then blood 
thus lost from an inflamed part is not all loss ; a great deal of it 
is black, "melanosed," partially dead and unfitted for the pur- 
poses of life, and only a minority of its constituents can really 
be called living. Then again, granting that loss of blood is a 
direct loss to a living body, still the indirect gain is a full com- 
pensation in cases where it is rightly applied. The blood-vessels 
resume their elasticity, their current renews its force, and a loss 
of substance is a regaining of function. So that a destructive 
becomes in the end a constructive remedy. 



208 • PLEURISY. 

In the action of poultices there is no even seeming paradox to 
stumble at. Continuous steady warmth is the most direct agent 
in our hands of vital development. It not merely fosters vital 
growth, but makes that growth take a higher form of life. Mr. 
Higginbottom found that different detachments of tadpoles kept 
in the dark and treated with different degrees of temperature, 
threw off their tails and branchise, and developed their lungs 
and became frogs, with a quickness exactly proportioned to the 
warmth they were subjected to.* Do not let any experiments 
on life escape you : turn to a practical use even that which seems 
at first glance most remote from practical use. Warmth, espe- 
cially when kept steady and even by moisture joined with it, has 
the same effect on the failing functions of tissues in the higher 
animals as in the lower ; it raises and restores the life to its 
normal force of development. If the milk is scanty in the 
breast of a suckling mother, a hot poultice or gentle friction 
with oil will revive its flow : if the liver ceases to make bile, hot 
fomentations will act as a cholagogue. As heat renews the 
vitality of the sluggish glands, so also it renews the injured 
membrane, which had been lowered to that condition we call 
congestion or inflammation, into the higher life of warm-blooded 
circulation. As it developed the tadpole into the frog, so it 
develops the half-killed diseased part into full life. 

You must take care not to follow up the application of quick- 
ening warmth by the depressing influence of cold, or it becomes 
doubly depressing by contrast. Your poultice must be kept on 
hot and hot till all pain is gone and the breath can be drawn 
quite freely and easily. And it will do no harm to beguile your 
patient into retaining it even a little longer, as was done in the 
case which is now my text. 

Such means will not fail to cut short an attack of pure 
pleurisy. 

* 20 tadpoles placed in a dark cellar at — 

56° produced in 89 days 10 frogs, 

53° " 103 " 10 " 

51° " 131 » 9 " 

—Proceedings of the Royal Society (1863). Vol. xi, No. 48, p. 532. 



PLEURISY. 209 

But you will say there are cases of pleurisy which are not cut 
short, and notably just now there is one a few beds off from the 
last patient, whose case I will extract from the case-book. 

John C, a railway navvy, aged thirty-four, always enjoyed 
good health till six months ago, when, on the third day after 
lying in a damp bed, he was seized with a violent sudden pain 
on the right side which obliged him to take to his bed. He was 
there a fortnight, and was treated with mustard plasters. He 
coughed up a good deal of frothy sputa, and was a little delirious 
several nights. The pain then shifted from the right side and 
settled in the left, but did not prevent his getting to work again, 
a month after the first attack. His work has not been hard, as 
he reckons hardness, and he has kept at it, with a chance day's 
exception, till his arrival here on June 25. The principal trouble 
he has had and the cause of his being off work sometimes, has 
been dyspnoea. He feels pain on bending forward and on 
drawing a deep breath. 

On auscultation in a sitting posture, there is very absolute 
dullness of the lower half of the lateral and scapular, and of the 
whole infra-scapular region on the left side. The rest of the 
thorax is resonant. When he lies on his belly and puts the 
shoulders below the level of the chest, hanging his arms. and 
head down, this infra-scapular region becomes more, but not 
quite, resonant, showing that the cause of the dullness is in part 
at least due to fluid which shifts about by the force of gravity. 
Still some dullness remains, and there is a whiffling sound with 
inspiration and expiration. And in the lateral region the dull- 
ness is unchanged by any posture. 

The secret history appears to me to be this — that the man 
was seized with double pleurisy, worse on the right side than the 
left — that the treatment relieved it — but that the left side being 
the least cared for, the inflammation spread to the pulmonary 
tissue, and caused its insidious condensation. The cause of the 
dullness on percussion is partly fluid which is affected by gravi- 
tation, partly solidified lung which is not so altered in its 
position. The fluid in the pleura and the condensed pulmonary 
tissue have mutually kept one another from being restored to 
perfect life. 



210 PLEURISY. ' 

Such is the most ordinary cause of those exceptional cases of 
pleurisy which become chronic. 

The longer they have lasted, the more obstinate usually are 
they in yielding. As respects treatment, you will find on the 
card the following, which may be considered the u processus 
integer' (as Sydenham calls it) of such cases: — 

June 25. Empl. Cantharidis (6 2 polliees) laterL 
Tfy Misturee potassse nitratis §j, 

Tincturse ferri sesquichloridi TTjxv. 

ter die. 
Jfy Pilulse hydrargyria 
tSeillw, 
Pulveris digitalis, aa gr. jss. 

omni node et mane. 

You will observe that the medicinal treatment is a union of 
destruction and construction ; it is designed to alter, as far as 
possible, the whole habit of the system — to cause by destruction 
a demand for new material, the supply of which is guaranteed 
by the iron. The mercury causes a general increase of meta- 
morphosis, the waste products of which are directed to the kid- 
neys by the squill and niter. The digitalis tends to relieve 
congestion by increasing the activity and tone of the blood- 
stream. So that by a union of virtues the combination prescribed 
in the pills will rarely fail to prove a powerful diuretic. 

The blister which has been put on the side will probably have 
to be repeated once, and perhaps again. You will observe 
however that I shall leave a considerable interval of time between 
each blister. I shall not apply first one on the side, then one 
on the scapula, then one beneath the collar-bone, stroke upon 
stroke, one on as fast as the other comes off. This is not an 
uncommon practice; and the object of it is to save time, by 
getting the two or three needful blisterings over as soon as pos- 
sible. I do not myself adopt it : and I will tell you why ; as the 
reasons give a very good example of the restorative system of 
medicine which it is my object to teach. 

The action of vesicants is first to destroy the epidermis and 



PLEURISY. 211 

to cause the exudation of a fibrinous scum beneath it. Very 
probably a similar but more remote effect is produced on the 
neighboring tissue of the pleural sac. Nevertheless it is not at 
this stage of the process that the chief benefit accrues. If you 
watch carefully the line of dullness marking the upper margin of 
the collection of fluid in the chest, you will find that it falls — 
not when the blistered skin is full of liquid and is discharging 
serum — not when the counter-irritation may be fairly concluded 
to be at its height — but after it is all over. As the sore heals, 
then the level goes down with the greatest quickness. That is 
to say, that the true use of blisters in such cases is to start a 
healing process, or a renewed life on the outside skin, in order 
that it may spread to the neighboring viscus inside. As long as 
this influence continues to be exerted, you will gain no time by 
a recommencement of the process, and your too hurried repetition 
of blisters would add to the patient's distress, without conducing 
to his cure. Wait till the effect of one blister has quite gone off, 
before you order another. 

Another case of pleurisy which has occurred this week, I do 
not cite as primarily instructive in a therapeutical point of view, 
for it was rather an instance of the weakness of our art — but as 
having a pathological interest. 

Charles D., aged eight, was admitted on June 24, with pysemia 
after scarlet fever, affecting the principal joints, and with an 
incipient slough on the sacrum. On July 1 he died. At the 
request of the parents the curator cut into one only of the joints, 
and that was tense with creamy pus ; so that the same condition 
may be assumed to have existed in all. On opening the chest, 
serum filled with flakes of fibrin gushed out from the right pleura. 
Bands of soft, elastic, straw-colored fibrin of an inch in length 
united the opposite sides of the whole pleura, and coated the 
surfaces with a honev-combed layer. The lung, pressed back ' 
against the spine, was non-crepitant, inelastic, and tough. Now 
the front of this boy's chest had been examined on the day of 
his admission by myself, the house surgeon, and clinical clerk, 
and I cannot but feel sure that had pleurisy existed at that period 
we should have found it out. Afterward, the wailings of the 



212 PLEURISY. 

poor child at the idea of being touched became so piteous, and 
the torture of moving the arms would probably have been so 
great, that an examination to discover the cause of the pain he 
complained of in the side was out of the question. The day, 
then, when the pleurisy came on is unknown, but it must have 
been less than a week before decease. 

What an amount of disorganization to have happened in such 
a short time ! What a quantity of serum and fibrin to be formed ! 
What a laying waste of the pulmonary tissue ! Pyemia is cer- 
tainly the most destructive result of an idiopathic poisoning that 
we know ; but yet, before seeing such a case as that of this 
child, we should scarcely believe the swiftness of its action to be 
so great. 

The moral is, if the march of death be thus hasty, let there be 
no delay in your remedies. Apply your cupping, or leeching (or 
faute de mieux venesection), your bedding and your poultices, 
your slops and your diuretics, without losing a minute. Do not 
leave alone patients to nature in any disease ; least of all in acute 
pleurisy, when really acute and dangerous. But I must warn 
you against looking upon this as a typical case. There was 
present in the body that frightful poison which produces the 
destruction of life we call pyaemia, and which would infallibly 
have proved fatal some other way had it not been so by pleurisy. 
The really typical cases are those which I described at the begin- 
ning of lecture as getting well by employment of the simplest 
restorative means, or even in spite of their neglect. 



LECTURE XVII. 

HYDHOTHORAX. 

Term " idiopathic hydrothorax" justified — Forms of pleuritic 
disease — Which form is here intended — Two cases — Hydro- 
thorax, a collection of fluid in the pleura — Difference between 
collection and effusion — Source of the fluid — Action of 
physical agents in the production of the disease — Treatment 
founded upon the pathology — Blisters — Poultices — Mercury 
— Food — Digitalis — Squill — Niter — Scoparium — Sequel of 
the second case, seven months afterward — State of chest, 
and explanation thereof — Another case of displaced heart — 
Treatment by paracentesis — Large quantity drawn off with- 
out return of heart — Comparison of these two cases as to 
treatment — Results inferred from them, and from an anal- 
ogous case of empyema, opening externally. 

(Clinical, St. Marys, November 22, 1861.) 

Two cases of idiopathic hydrothorax in the wards shall supply 
us with instruction to-day. 

Idiopathic "hydrothorax," or "hydropleurisy," is an expres- 
sion which I find requires a defense. In the " Cyclopaedia of 
Practical Medicine," and in the "Library of Practical Medi- 
cine" (whose good indices render them the most frequent books 
of reference for busy men), the existence of such an idiopathic 
state is denied altogether. Effusions of fluid into the pleural sac 
are stated always to depend either on some visceral cause of 
dropsy, such as organic changes in the heart, liver, and kidneys, 
or to consist of pus, when the case acquires a title to be classed 



214 HYDROTHORAX. 

as empyema. An acute collection of serum in the pleural sac 
from causes depending on the pleura itself, is either ignored 
altogether, or merged in the common description of "pleurisy." 
This I hold to be bad pathology, likely to lead to bad practice. 
That a quantity of fluid sufficient to fill one side of the chest to 
complete dullness, that is to say between four and five pints, 
should disappear in ten days or a fortnight, is surely conclusive 
against that fluid being pus. Pus is absorbed, if absorbed at all, 
with extreme slowness. 

Then as to the undifferentiated classification of these cases as 
" pleurisy," — is that practically correct ? Let us examine. Half 
of our pleuritic patients have no fluid collected at all ; there is 
pain in the side, and rubbing sounds on auscultation of the 
roughened surfaces, but no dullness on percussion. This is 
" pleurisy pure" and gets well fast enough when treated as 
such. Then, again, there are very severe inflammations where 
the dullness is unfortunately due to pus. This is " pleurisy with 
empyema" and requires the empyema to be Seated as well as 
the pleurisy, if it is to be cured. Then there is a third class 
where all the general symptoms, such as pain on inspiration, 
fever, and so on, are accompanied by stethoscopic signs of a 
moderate collection of fluid, but whose rapid absorption shows it 
to be serum. This is " pleurisy with serous effusion." But the 
serum is not a matter of importance ; it causes no increase of 
dyspnoea beyond what is due to the pleurisy, and it disappears 
without any special treatment when the pleurisy is cured. The 
medical attendant is wise to think much about the pleurisy and 
little about the serum. 

There is a fourth class, to two examples of which I call your 
attention to-day, where this condition is reversed, where the 
pleurisy is absent, or of small moment, and the amount of serum 
is great ; and where the nomenclature, if it is to be of use, must 
indicate this. Here the practical physician feels that what he 
has to attend to is primarily the serum, and secondarily only (if 
at all) the pleurisy, and he requires a word to express this state 
of things. With Laennec, I would advise adherence to the name 
"idiopathic hydrothorax," meaning a collection of serum in the 



HYDROTHORAX. 215 

pleural sac injurious to health from its quantity, and arising 
from an abnormal state of the pleura itself. 

Case 1. — Maria Gr., a housemaid aged twenty, has always 
enjoyed sufficiently good health to continue in domestic service, 
though subject sometimes to "bilious headaches," to pain in the 
hepatic region, sties in the eye, and irregularities of the cata- 
menia. She easily catches cold, and has habitually a dry cough, 
but never expectorated blood or indeed any sputa at all. Her 
father died at forty, of some chest complaint, but her mother is 
alive and well, and she has not lost any collateral relations in 
adult age. In short, though she is well grown and hearty look- 
ing, her constitution, perhaps inherited from the paternal side, is 
endowed with little power of resistance to external influences. 
She is just the sort of person who might through force of un- 
toward circumstances develop tubercle; though I feel sure she 
has not done so as yet. I say she has not done so as yet, because 
such a constitution as hers gives way very rapidly when once 
disease has begun ; and she is also very sensitive, so that she 
would be sure by this time to have shown it, did any internal 
organic lesion exist. 

She was in her usual health up to October 27 last, and had 
menstruated naturally the week before. On that day and on the 
28th, without any assignable cause, she felt " giddy, nervous, 
and ill ;" and in the evening of the 28th she felt a difficulty in 
breathing, with a stabbing pain in the right side. The sharpness 
of the pain lasted three hours, when it went off, and was followed 
by what she describes as an "aching." On the 29th, she went 
to a neighboring surgeon, who sounded her chest, gave her some 
pills and medicine, and bade her call again in a week. From that 
time up to her entry into the hospital she was unable to work ; 
the dyspnoea kept on increasing, as did also a sensation of tight- 
ness round her waist ; she lost her appetite, and was thirsty ; 
she had also frequent shiverings during the week, but cannot fix 
the date of the first. 

I saw her first on November 6. She had to be propped up in 
bed from the orthopnoea and dyspnoea under which she labored. 
There was complete dullness of the whole of the right side of the 



216 HYDEOTHORAX. 

chest, except a small piece beneath the clavicle, which was 
resonant as compared with the lower part, but still dull as com- 
pared with the other side. In this part alone were there breath 
sounds to be heard; and these were of a bronchial character, 
like the noise produced by blowing in and out through a stetho- 
scope. The pulse was small, 120. The tongue was quite clean. 
She was ordered Jfy Pilulae hydrargyria Scillee, aa gr. jss, Pul- 
veris digitalis, gr. ij, in piluld ter die cum haustu sequenti — 3^ 
Potassx nitratis, gr. xx, Spiritus setheris nitrici, H]xx, Mist 
camphorse, §j ; and a poultice was continuously applied to the 
right side of the chest. Diet : two pints of beef -tea, one pint of 
milk, bread ad libitum. 

Nov. 8. — The breathing is more labored ; the dullness on 
percussion reaches higher ; the pain has returned to the right 
side of the waist. Applic. cue. cruentse ad Sviij, lateri dextro ; 
perstet in usu pilulse et haustus ter die. 

Nov. 9. — The sense of tightness and pain around waist are 
much relieved since the cupping. Otherwise there is no change 
in symptoms. Add to diet another pint of milk. 

Nov. 10. — The same report. Emplastrum cantharidis lateri. 

Nov. 15. — The gums feel, but do not look, sore. The breath- 
ing is decidedly easier, but I can remark no diminution in the 
extent of dullness on percussion. Omitte pilulam in unam diem. 
Add to diet an egg and rice pudding. 

Nov. 16. — There is a decided improvement in the breathing. 
She can lie down with the addition of only an ordinary pillow to 
the bolster. There is breathing of a mixed bronchial and vesicular 
character over the whole infra-clavicular and over part of the 
mammary region, and more resonance on percussion. No rales. 
Resumat pilulam bis die. Ify Decocti scoparii §jss ter die, vice 
haustus nitri prioris ; repetatur empl. cantharidis. 

Nov. 18. — Chest quite resonant in front. Beneath the scapula 
behind there is dullness on percussion, and gegophony. The 
gums not sore, but there is a mercurial taste in the mouth. 
Perstet in usu pilulse et haustus. Diet "simple," — mutton-chop, 
two pints of milk. 

Case 2. — -Annie M., wife of a builder's clerk, aged twenty- 



HYDROTHORAX. 217 

seven, of a healthy long-lived family, has never been ill since the 
age of fifteen, when she had influenza for a fortnight. She has 
once borne twins, who died, but she has two living children, the 
last of whom was born May 28, and she suckled him up to Oc- 
tober 14, when she was forced to desist by her present illness. 
This illness she accounts for by the following history : 

During the first week of October her baby had an arm very 
sore after vaccination ; and she fed him from the left breast 
exclusively to avoid rubbing the tender place. To soothe the 
natural crossness of the infant she used to do this even out of 
doors, and once when so engaged under a tree in Kensington 
Gardens she felt much chilled. 

During the second and third weeks of October dyspnoea grad- 
ually came on, accompanied by an uncomfortable feeling, by 
degrees amounting to pain, in the cardiac region, so that she told 
her husband she felt sure something was the matter with the 
heart. She positively denies having felt any stitch in breathing, 
or other pain in the side ; she did not lose appetite, and did not 
experience any thirst, or other signs of fever. Her complaint 
was of dyspnoea, pain in the heart on exertion, and a dread that 
she was going into a consumption. This dread was increased by 
the coming on of a cough, accompanied by much expectoration 
of glairy matter. 

She was admitted into St. Mary's Hospital on November 1. 
On examination, the whole left side of the thorax was absolutely 
dull; it was nearly two inches by measurement larger than the 
right round the lower part of the waist, and there was entire 
absence of breath-sounds. The heart was dislocated from its 
usual place; the apex could not be distinctly found to impinge 
anywhere, but the general pulsation was felt partly in the epi- 
gastrium, partly behind the cartilages of the right ribs — not at 
all in the cardiac region. She could not breathe when lying 
down, and the inspirations were irregular, shallow, and frequent. 
On the right side there was excessive motion of the ribs and 
puerile breathing. The sputa consisted of transparent mucus 
with but little froth. The pulse was upwards of 120, sometimes 

15 



218 HYDROTHORAX. 

irregular and intermittent. The appetite was natural ; there was 
no thirst, and the tongue was clean. 

The patient was ordered "half ordinary diet," a pint of beef- 
tea, and a pint of milk daily. A blister six inches square was 
put on the left side, and the following drugs prescribed : 
1^ JPulv. digitalis , scillse, pil. hydrargyri, aa gr. jss; omni node 
et manS. ^ Potassse nitratis, gr. xx; Spiritus setheris nitrici, 
TT|xx, Mist, camphorse, §j ter die. 

November 4. — Her breathing is equally laborious. The sputa 
are more copious, and the cough increased, probably by a draught 
from the window upon her bed. Pulse 100, weak. No change 
in medicine. Blister repeated. Add an egg to diet. 

Nov. 9. — The breathing is easier since last report, and the 
measurement of the thorax three-quarters of an inch less. Add 
a bottle of stout to diet. 

Nov. 11. — She says she coughs only in the daytime, when 
there are windows and doors unavoidably open in the ward. She 
lies on the affected side without pain or inconvenience to the 
heart, though it still remains dislocated. Diet "simple" with 
one chop, one egg, one bottle of stout. 

Nov. 14. — Soft and distant breath- sounds with inspiration and 
expiration under left clavicle. 

Nov. 15 to 18. — The medicine was omitted, and effervescing 
draughts with prussic acid were given on account of nausea and 
vomiting, which did not come on after eating, but occurred the 
first thing in the morning, when the stomach is empty. 

Nov. 18. — She resumed the medicine before prescribed. 

Nov. 20. — There is very little, if any, diminution of dullness 
on percussion since admission, although air now enters the upper 
lobe. The fluid does not seem to have been continued to be ab- 
sorbed since the 14th. Perhaps this non-diminution of dullness 
arises from the partial return of the heart to its place ; for the 
organ can now be felt pulsating behind the cartilages of the left 
ribs as well as on the wrong side of the chest. Pulse 100, of 
good power. The stout caused her face to flush after dinner, so 
it is left off. Other diet as before. 1^ Pil. hydrargyria gr. iij ; 
Scillse, Pulv. digitalis, aa jj, ter die; Potassee nitratis, gr. xx; 



HYDROTHORAX. 219 

Spiritus setheris nitrici, Tt[xx; Misturse camphor ee, Sj ter die ; 
repetatur emplastrum cantharidis. 

In the first of the cases I have narrated (that of Maria Gr.) 
there is every reason to believe that the abnormal state of the 
pleura was of an inflammatory character. The pain in the side, 
the stitch on inspiration, the rigor, the loss of appetite and fever - 
ishness, all support the opinion that there was inflammation of 
the serous membrane. And probably there was fibrinous exuda- 
tion too, as there usually is in even slight pleurisy. But this 
attack seemed to have been of a very unimportant character in 
itself; she was not confined to bed, and the excellent practitioner 
whom she consulted in the first instance "gave her some physic 
and pills, and told her to call again in a week," so little did he 
think of it after examination of the chest. It was of an unim- 
portant character in itself, but it led to results which might have 
been very serious, perhaps fatal. 

In the second case there is nothing that you can set down as 
evidence of pleuritis. The patient is of a nervously sensitive tem- 
perament, very susceptible of physical or moral pain and pleasure, 
so that had there been anything disagreeable to feel she is not 
likely to have forgotten it; yet she most positively avers that 
there never has been since she was taken ill any stitch in the side 
or catching of the breath in inspiration; the only pain in the 
chest at all being that arising from the forcible dislocation of the 
heart, and closely connected with its struggling palpitations. 
There was no rigor, no thirst, furred tongue, or loss of appetite, 
such as accompanies pyrexia. Yet the hydrothorax is greater 
in extent, and is rather more obstinate against remedies than in 
the former instance. 

We have, then, got so far on with the pathology of idiopathic 
hydrothorax as to be able to say that — 1st. It does not follow 
severe pleurisy, — for that produces pus and fibrin in quantity 
proportioned to its intensity, and not serum. 

2d. It sometimes follows slight pleurisy, as probably here. 

3d. The pleurisy is sometimes so slight, that it may come 
under the rule de non apparentibus. 

Yet that the cause of the hydrothorax is the pleura itself, we 



220 HYDROTHORAX. 

can hardly doubt, when we find all the other viscera painless, 
apparently normal, and doing their duties in the usual manner. 
Moreover, it is absorption, a function of the pleura, the want 
of which truly constitutes the disease. You must not let the 
commonly used but deceptive word " effusion," mislead you into 
viewing dropsical fluids as products of extra exertion on the part 
of the sacs which contain them. Like all morbid phenomena, 
dropsical fluids are proofs of sluggishness, of deficient vitality. 
In full vigor of health, the pleura, pericardium, and other similar 
membranes probably pour out a much greater quantity of fluid 
than they do in disease : this fluid, in the normal state, is taken 
up again by absorption as soon as exhaled, so that on opening 
the serous sacs we find them damp, indeed, and dripping, but 
empty. By disease absorption is stopped or at least slackened, 
and the natural transudation still continuing, a collection of its 
products remains ensacked. Think of dropsy as a collection, 
not as an effusion, and your pathology will be right. 

Do you ever, while looking in a dead body at these thin, ap- 
parently unimportant, membranes— seemingly only the sacs, as 
they are called — do you ever reflect on the business they transact 
when they are alive? The experimental observations of phys- 
iologists tend to assign to them an activity almost incredible, 
and pathologists will do well not to neglect the hint. Professor 
Lehmann* opened the pericardium of a healthy criminal, and 
collected the fluid which ran from it in three minutes and a half. 
It amounted to 33-8 grammes (9J fluidrachms). If always ex- 
haled at that pace, the quantity in twenty-four hours would be a 
gallon and a half from the pericardium alone ! — equal to about 
one-sixth of the whole weight of an average man. This in a state 
of nature would be immediately reabsorbed; and lest we might 
hesitate to credit the serous membranes with such an enormous 
power of endosmosis as well as exosmosis, we can refer to Dr. 
Richardson'sf experiments, which exhibit this power in action. 
This physiologist injected into the peritoneum of a dog weighing 
23 lbs. water to the extent of 4 lbs., or more than one-sixth of 

* Lehmann's "Physiol. Chemie," ii, 309. 

f Dr. Richardson on ^he "Coagulation of the Blood," Exps. 36, 37, 38, 39. 



HYDROTHORAX. 221 

its weight. Twelve hours afterward the animal gradually sank, 
and was examined an hour after death. Not a trace of fluid 
was found in the peritoneum. It had all got into the veins, and 
caused death by dilution of the blood. Three repetitions of the 
same experiment produced results essentially the same, the injec- 
tion of a quantity of water equal, or nearly equal, to one-fifth of 
the weight proving fatal by artificial anaemia — not by retention 
of the fluid in the serous sac, but by its being taken into the cir- 
culation. When a less quantity is injected, the animal recovers 
in about three days ; but even in the fatal cases, the serous mem- 
brane does its duty, in taking up with an almost incredible ac- 
tivity the water presented to it. 

When you reflect upon the activity of the serous membranes 
in a normal state, you will have no difficulty in understanding 
where the great mass of fluid comes from in dropsies of the serous 
sacs. Nor will you fail to see whither it ought to go. And then 
you will clearly see that the disease to be treated is no excess of 
life, no exaggerated transudation, but a defect of life, an arrested 
absorption. 

How do the physical agents to which illness is traceable beget 
the varieties of pleural disease which I have noticed? When 
by the impression of cold, or by direct mechanical injury, an 
inflammation of the pleura is produced, with great congestion of 
the veins at first, and afterward with a copious formation of 
fibrin, the absorption indeed is interfered with most forcibly ; but 
yet it is not these severe pleurisies in which you have the largest 
collection of fluid. The reason of which is that the normal ex- 
halation is then slackened at the same time. But it is arrested 
by a less severe impression than the absorption is; and either 
only a local obstruction of the absorbents may take place by a 
local formation of fibrin or by congestion, or a partial arrest of 
it throughout the whole area by a force unequal to the production 
of actual inflammation. In each case, the exudation remaining 
nearly normal quickly causes a copious collection of fluid. The 
reason why hydrothorax is not more common, is that usually the 
arrest of the exudation is contemporaneous with, and in propor- 
tion to, that of the absorption. 



222 HYDROTHORAX. 

On this pathology is founded the treatment. The aim is to 
restore the function of absorption, and to that end our remedies 
are directed. I will remark upon them severally. 

Blisters. — I will not insult pupils who have gone through a 
course of physiology by supposing that they would do anything 
but smile at the vulgar idea that blisters do good by "drawing" 
to the outside the fluid from the inside ; for it must be obvious 
to the most superficial medical student, that the quantity thus 
elicited is too small to be of any service. But still perhaps you 
may not have clear notions as to their real action; and therefore 
there is danger of your sometimes applying them wrongly. The 
true profit to be got out of cantharides is, in the first instance, 
the encouragement of absorption, a power which is exerted over 
fluids and solids equally, and therefore is quite independent of 
the evacuation of serum by the cutis. The explanation of the 
steps in this process most reconcilable to physiology, is the 
attraction of blood toward the capillaries of the skin in the first 
place; secondly, its dispersion, and the consequent quickening 
of the capillary circulation in the neighboring parts. With the 
quickened capillary circulation follows increased endosmosis, ac- 
cording to the well-known law, that the attraction of fluids 
through membranes is in the direction of the fluid set in motion, 
and proportioned to the rapidity of the motion. A further ad- 
vantage is derived from the renewal of growth which is entailed 
on the tissues by the self-renewing skin. The process seems to 
be propagated to surrounding parts, notwithstanding dissimilar- 
ity of tissue. 

The practical knowledge to be derived from this physiological 
view of the action of a blister should teach you patience in wait- 
ing for the advantages to be derived from it; for they are ob- 
viously by no means limited to the period of its application, but 
rather begin after it is removed, and continue even after the sore 
place is healed. You may also learn by this view of its action 
not to torture your patients needlessly by keeping the blister on 
too long, under the mistaken idea that you cannot have too much 
of a good thing. 

In some cases I do not even allow the blister time to raise the 



HYDROTHORAX. 223 

scarf-skin, so that I may have the opportunity of repeating it in 
the same place. But, as a general rule, I think the detachment 
of the epidermis desirable, for it appears to me that absorption 
is particularly active during the growth of the new skin. Per- 
haps the capillary circulation is quickened by the demand for 
new material entailed by new growth, and perhaps the industry 
of increased life may spread to the neighboring absorbents and 
solid tissues. Whatever the explanation may be, the fact is that 
during the healing of a blistered surface its chief benefits are to 
be found. 

Next in power to blisters come poultices. Their action in a 
great measure depends on the continued moist warmth acting 
on di-osmotic processes according to the law of their augmenta- 
tion by heat. But it is also partly in a more special manner 
vital ; for the skin is reddened, swelled, and made more delicately 
sensitive by their application. They are useful in pleurisies and 
moderate collections of fluid, when their size needs to be mod- 
erate only; but it is inconvenient to keep the whole side covered 
up with a poultice, and if they are not constantly put on hot 
and hot, the surface is apt to get chilled. 

Mercury distances all the contents of our pharmacopoeia in 
the power of hastening destructive metamorphosis. Under its 
influence all the excretions are increased at the expense of the 
tissues. It is quite true that by such a process nothing is directly 
gained in cases like those before us ; there is no poison to 
evacuate, and the debility which follows is so much ground lost. 
Harm certainly is done by it, but with the harm is joined a good 
which I think is worth the loss. No drug so consistently and 
steadily aids absorption as mercury, and nowhere can you trace 
its effects so easily as in hydrothorax. In the history of both 
these cases you may observe that no immediate improvement 
follows the ingestion of the remedy ; but that immediately on its 
pathogenetic effects being produced, immediately on the gums 
becoming tender, the dispersion of the fluid can be tested by 
relief to the breathing and commencing resonance on percussion. 
And from this point a steadily advancing progress is made to 
recovery. 



24 HYDROTHORAX. 

I would wish you to remark that the relief to the dyspnoea has 
preceded by a short time the return of resonance, especially in 
the woman whose hydrothorax is on the left side. The reason 
is that when a certain quantity of fluid is removed, the emptied 
space is filled up in both instances by the re-expanding lung, and 
in the left side by the return also of the dislocated heart. It is 
necessary to note this in order to trace correctly the period when 
the remedy begins to work. 

When absorption is once set agoing, it is not necessary to con- 
tinue the full doses of mercury ; if any evil accrues from it, you 
may leave it off altogether ; for its beneficial effects, like those 
of blisters, may be calculated upon as likely to continue after its 
intermission. 

And you may also avoid the injury liable to accrue from the 
destructive drug by amply supplying the materials to take the 
place of the loss. Be very careful that your patient has food in 
the most frequent doses possible, in the largest doses that will 
not give nausea, and in the forms most easily digested. You have 
seen this aimed at in the dietaries of the cases under your notice, 
on principles which I need not again recount. 

Digitalis, squill, and niter were ordered for their diuretic 
qualities only. That they all, both separately and combined, 
increase the quantity of the urine, is established by observation ; 
and that such action is beneficial in dropsies, is a traditional 
belief. For my part I have no reason to doubt it, for I remember 
as a student to have seen patients recover in whose treatment the 
diuresis was the only therapeutic agent that I could at all recon- 
cile with rational physiology. Diuretics do not promote absorp- 
tion in the same manner as mercury, by the hastening of destruc- 
tive metamorphosis. The experiments collected by Dr. Parkes* 
show that though the water of the urine is augmented, yet that 
the daily excretion of urea is either diminished or unaffected, 
thus proving that at least one great class of the constituents of 
the body, namely, the nitrogenous, is exempted. This con- 
sideration has an important bearing on practical medicine, for it 
allows us freely to administer these reagents combined with 

* "Parkes on Urine," pp. 158, 1*70, 173. 



HYDROTHOKAX. 225 

mercury, without fearing that we shall thereby add to the un- 
avoidable evils of that mineral. 

Scoparium. — The most memorable example to my own mind 
of the good effects of broom-tops, is that of a case in which I 
differed in opinion with a patient, and in which he was right 
while I was wrong. A poor fellow with a slowly growing malig- 
nant disease of liver and peritoneum was taking under my orders 
this remedy for the ascites caused by the abdominal tumors. It 
still increased, and pressed upward the diaphragm so much that 
I wished the peritoneum to be tapped. He flatly refused, and so 
of course ceased to be a patient of mine. About six months 
afterward he came to me again with an extension of cancer to 
the costal periosteum, of which he shortly afterward died. To 
my surprise I saw his ascites was all gone, and inquired who had 
cured it. He stated that he had continued the use of broom-tea 
for two months after his dismissal from my care, and that during 
that time his abdomen was reduced to its natural size, and had 
not again swelled. Surely a course of treatment under which 
dropsy due to increasing malignant tumors has got well, must 
have no ordinary power. 

Besides acting as a diuretic, broom has the additional advantage 
of giving an appetite by the bitter which it contains. 

{Clinical, St. Marys, June 21, 1862.) 

During my visit a few days back a young married woman was 
in the ward, — Annie M., about whom I gave a clinical lecture on 
hydrothorax at the end of last November. You may remember 
that then her chest was filled with fluid and the heart pushed 
over to the right side. She did not come for advice, but to thank 
me and show her chest, which I was curious to know the state of. 
We found that the heart had returned wholly to its natural site, 
and that there was to be heard vesicular breathing, mixed with 
a few occasional crackles, throughout the pulmonary tissue. The 
lung has expanded, lets in air, and does its work. It has ex- 
panded, but it has not expanded to its full size, nor does it let 
in all the air it ought. For on percussion the part below the 



226 HYDROTHORAX. 

clavicle is still dull, and is flatter than the opposite side, and the 
left ribs do not open out with inspiration so well as the others. 
I have no doubt that from long compression the lung tissue has 
partially degenerated, and that it will be months, perhaps years, 
before it recovers its full life. Her occupation of nursing a sick 
husband is not the most favorable one for regaining vitality, but 
still you see her in as fair a way to do so as can be expected 
under the circumstances. 

Over and above the possible degeneration of the tissue, there 
may be another cause for the dullness on percussion. I pointed 
out to your notice in the wards a week or two ago a vessel of 
serous fluid, which had been drawn off by paracentesis from the 
thorax of a patient of Dr. Sibson's. It was transparent, straw- 
colored, and not perceptibly reddened by blood. In the center 
of the porringer floated a delicate fibrinous clot, just such as 
forms in blood, but wanting the red globules. It was coagulable 
fibrin that had coagulated after being drawn off. Now if this 
fibrin should collect and be coagulated inside the pleural sac, it 
clothes the lung with a strong coat which impedes its expansion ; 
and if it form also a layer over the costal pleura, each fibrinous 
mass would separately produce partial dullness on percussion, 
without the pulmonary tissue being seriously the worse for it. 

I am glad Annie M. came to show herself just now, as you 
have under your eyes a case very similar to hers, where a some- 
what different treatment has been pursued. 

James S., a tall and muscular day-laborer, aged twenty-six, 
was admitted May 30, 1862. For nearly a year he had found 
his breath short, but was not so seriously hampered by it as to be 
obliged to give up work, till last Christmas. Shortly before that 
date he says he remembers observing that his heart beat on the 
right side of the chest instead of the left. That symptom was 
certainly very conspicuous on his admission ; you could not hear 
or feel a trace of heart-strokes except on the right of the median 
line, and there they were very strong and loud. So one can 
easily conceive its having been remarked even by an unprofes- 
sional person. There was an entire absence of breath-sounds on 
the left side, which also was absolutely dull on percussion. 



HYDROTHORAX. 227 

Several careful examinations on successive days by different 
parties made sure of the fact that the left side was not in the 
least dilated, eighteen inches from median line to spinous process 
being the exact measure of the semicircumference of the thorax 
on the left and right. 

He is a hearty strong man with the exception of dyspnoea, and 
appears to have no other disease about him beyond that of the 
pleura. 

He was at first treated with the diuretic pill (Pil. hydrargyria 
pulv. digitalis, scillse, aa gr. jss) every night and morning, a 
draught containing niter and iodide of potassium three times a 
day, and a large blister to the side. But after a week of this 
treatment no ground seemed gained, no respiration was to be 
heard in any part of the left lung, and the heart seemed if any- 
thing rather more over to the right side than before. He him- 
self thought that the dyspnoea was increased. I therefore tapped 
the chest with a small trochar between the fifth and sixth ribs in 
the lateral region, and drew off sixteen fluidounces of fluid, and 
then continued the same treatment as before, to try and encourage 
absorption. 

The fluid drawn was a yellow serum slightly opalescent. After 
standing, it deposited some of the gray opaque matter which 
caused its opalescence. The opaque matter examined under the 
microscope was seen to consist of fine granules, irregularly con- 
glomerated into globules of various sizes. The application to it 
of acetic acid did not exhibit the presence in those globules of 
any nucleus, but rather dissolved them, and rendered them still 
less like pus than they were previous to its application. 

My own impression is, that the granular matter is fibrin 
altered by long soaking in serum — the same fibrin in fact which 
I showed you, showing signs of recent life by coagulating into a 
clot, in the fluid drawn from Dr. Sibson's recent case ; but which 
has become by time dead and unable any longer to coagulate. 
It is the fibrin which is exhibited in ordinary blood-serum, and, 
after exuding through the coats of the vessels, is still found in 
the more watery serum of serous sacs. 

On the day of the operation there was some bronchial breath- 



228 HYDROTHORAX. 

ing to be heard beneath the left scapula, but the dullness of the 
left chest on percussion, and the dislocation of the heart, were 
unaffected. 

Two days after that I could not hear even the bronchial 
breathing, and the patient seemed in no better case than on 
admission. 

Four days after the first tapping he was tapped again to the 
extent of eighty-eight fluidounces. After this, breath-sounds 
were to be heard very distinctly in the lower lobe, but not in the 
upper. 

On the 18th of June the diuretics were left off, and the fol- 
lowing prescription was ordered : 

^ Quinde etferri citratis gr. v, cum olei morrhuse 5ij> ter die. 

Though the diuretics seemed to be doing no positive harm, yet 
I thought it possible that tonics would do him positive good, and 
ordered them as above described. 

He was allowed to have full meat diet, and also to get up and 
walk about ; for I have noticed that absorption will often take 
place quicker when the patients are in the erect posture than 
when they are confined to bed. 

(Case continued in a subsequent lecture, July 19, 1862.) 

One would have thought that enough liquid had been drawn 
from James S. to allow the heart to return to its place. But it 
was not so. On the 6th of July, five weeks after admission, he 
was punctured again and fluid let out to the amount of forty-four 
fluidounces. He has also had the chest painted with iodine to 
encourage absorption. But the heart has not come back. 

This advantage only is gained, that the pulmonary tissue has 
been gradually returning to its allegiance ; there is very fair 
breathing beneath the scapula and some in the lateral and in the 
supra-mammary regions. 

You may have remarked that the lung remained dull after 
each tapping, although the breath-sounds increased. This I con- 
ceive to be due to a layer on the pleura of that fibrin which I 
have pointed out to you as a natural constituent of the serum in 



HYDROTHORAX. 229 

both the recent and more chronic forms of hydrothorax. I be- 
lieve the abnormal coating binds down the lung, preventing its 
expansion, and counteracting the remedial action of the opera- 
tion. So that much less than you might have expected has been 
gained by it, and the patient remains on hand as long as the 
young woman, Annie M., whom I showed you in the ward and 
lectured about a month ago, and who was not tapped. In fact, the 
chest refuses to be hurried by violence and must take its own time. 

I say this not to discourage you from practicing the operation 
of paracentesis ; for it is an easy, safe operation, and in recent 
cases very effective ; but simply to prevent your disappointment 
in case you should anticipate too immediate benefit therefrom in 
chronic collections of fluids. 

As an experiment upon the heart, I have had James S.'s chest 
bound up with a stout tight bandage, as if the ribs were fractured. 
The design is to make the bony parietes of the thorax a fixed 
point, so that the healthy right lung may compress the heart by 
its expansion ; and as it moves more than the left imperfect lung 
by reason of its healthiness, it may possibly assist in reinstating 
the displaced organ. All I can report upon the experiment as 
yet is that it seems to do no harm, but I cannot say it does any 
good. 

The patient also continues his tonic treatment, and I think 
that each time I listen the breathing in the lower lobe is more 
distinct. The upper lobe expands much more slowly. I sup- 
pose the diaphragm has not the same power over it to draw the 
air in, and so we find only an indistinct distant breathing in that 
part. 

You will probably ask what is likely to be the result of this 
case. In answer I refer to that of Annie M., which was one 
exactly similar.* And I may refer also to another, not indeed 
of hydrothorax, but of a disease whose mechanical relations to 
the chest are closely analogous, empyema thoracis. 

* Shortly afterward this man, James S., returned to work at his own request. 
T did not dissuade him, as he was able to run up stairs without dyspnoea, and felt 
sure he would be able to earn a fair day's wages. The heart however remained 
beating on the right side. I have not heard of him since then. October, 1863. 



230 HYDROTHORAX. 

An old patient of mine, formerly a horse-jockey, aged now 
fifty-four, is occasionally to be seen about the streets near here, 
whose chest presents a striking instance of the form which con- 
tracted ribs assume. It is a case not indeed of hydrothorax, but 
of empyema after pleurisy, which occurred in this hospital in 
1857, and is reported by the then house surgeon, Mr. Ash, in 
the "Lancet" for May 31, 1862. The empyema was cured in 
the only mode in which it can be cured, namely, by the external 
discharge of the pus. Thus the chest was put into the same 
relative mechanical condition as is that of the patient now in the 
wards upon whom I am lecturing. The heart, which had been 
displaced to the right side for two months, returned to its place 
in about a month. After that the ribs fell in, and became flat- 
tened very gradually, so that they did not attain their utmost 
flattening till the autumn of 1859, two years after the empyema. 
And then how were they flattened ? — not in the part where 
the empyema had been, and whence it had been discharged — 
not in the lower part of the thorax — but beneath the clavicle, 
which is so depressed that the man looks quite lop-sided as he 
walks. 

I fully expect the ribs of our present patient will fall in after 
the same fashion, and that his heart will in due course of time get 
back to the right place, but that as the displacement has lasted 
longer, so that the restoration will be longer about. 

It may be remarked further, that in the lop-sided old jockey 
the ribs, though flattened, move freely and equally on both sides 
with the breathing, and that the air enters the two lobes of the 
lung on the formerly affected side fully and equally. This is 
a cheering observation; it encourages us to prophesy ' that 
our present patient also will with time recover the full use of 
his lungs. 



LECTURE XVIII. 

ACUTE LARYNGITIS. 

Case related — Important point in the pathology of the disease is 
its locality — Tracheotomy must not be represented as a last 
hope — Reasons for delaying it and reasons for not delaying 
it — Care of digestive organs — Wine — Solid food — Antimony 
— Mercury — Laryngitis, acute and chronic — Difference in 
pathology and in principles of treatment. 

{Clinical, St. Marys, October 25, 1861.) 

Maria F., aged twenty-two, a domestic servant, was placed 
under my care a fortnight ago. It appeared that she came first 
as an out-patient, with a catarrhal cold of head and chest of a 
few days' duration. But she found so much difficulty in breath- 
ing that on the second day of her attendance she could not leave 
the hospital, and was sent up to bed. She was, when first seen 
(on October 12), cold and shivering, her face was livid, her pulse 
weak, her breathing labored, noisy, and spasmodically irregular. 
There was also slight fullness of the throat and tenderness 
on pressing the upper part of the larynx. She was ordered 
inhalations of hot steam, and frequent teaspoonfuls of hot beef- 
tea and wine; four leeches were applied to the trachea, and a 
draught of an ounce of decoction of cinchona, and a drachm of 
compound tincture of cinchona, ordered to be taken every alter- 
nate hour. 

Next day, October 13, it is reported in the clinical case-book 
of Mr. Young, the house surgeon : 

" She passed a very bad night. The dyspnoea is increasing ; 
but she was able to swallow till 11 A.M., with difficulty. The 



232 ACUTE LARYNGITIS. 

throat is more tender. She is obliged to be propped up in bed, 
as she could not breathe in any other position. There is slight 
cough, the face is flushed, the lips livid, the eyes swollen, and 
countenance anxious. These symptoms gradually increased till 
7.30 p.m., when she was found gasping for breath, and asphyxia 
was fast coming on, when a little chloroform was administered, 
and Mr. Young performed tracheotomy. After the operation, 
the pulse was 100 ; she was able to swallow, and expressed her- 
self greatly relieved. 

"Oct. 14. — She could not sleep very well. She took a little 
nourishment. The breathing was tranquil. She was ordered to 
have an enema of mutton-broth, with ten minims of laudanum 
every three hours ; and also as much nourishment as she could 
take by the mouth. 

u Oct. 15. — She slept pretty well. Pulse 100. Tongue furred. 
Slight cough. She breathes a little through the nostrils. 

" Oct. 16. — The trachea and larynx are not so tender. Pulse 
98. 

" Oct. 17. — The tube was withdrawn, and she breathes tran- 
quilly. The bowels have not acted since the operation. A 
simple enema was ordered at bedtime. Her appetite is very 
fair ; she is able to take three eggs, beef-tea, &c, in addition to 
enemata of mutton-broth. 

" Oct. 18. — The bowels acted freely. The wound is granu- 
lating a little. Air still passes through the opening, which is 
covered by a piece of muslin gauze. 

" Oct. 19. — She is cheerful. Tongue cleaning at edges, but 
still very much furred in center. Pulse 95. 

" Oct. 21. — Pulse natural. She sleeps tolerably well. She 
has slight cough, and expectorates a little. 

" Oct. 23. — The appetite improves. She was ordered to have 
half a dozen oysters daily in addition."* 

****** 

Inflammatory laryngitis (or rather glottitis) is a disease in 
which the power we wield of saving existence by restoring a 

* The wound healed on October 28, and on November 4 she was employed in 
assisting the nurses in their care of the sick. 



ACUTE LARYNGITIS. 233 

deficient function is most strikingly exhibited. What a paltry 
scrap of flesh is damaged !* Yet how frightful the results are to 
witness ! The question of life or death is a question of an eighth 
of an inch more or less diameter in a tube. If the same amount 
of inflammation were in your finger or at the end of your nose, 
anybody would laugh at you for going to a doctor about it ; if 
it were in your digestive canal, you would perhaps stay away 
from lecture, and take some slops, but you would not care to 
make an accurate diagnosis of its whereabouts. Catarrhal 
inflammation may even attack the lower part of the larynx 
itself pretty severely, and yet what one may call " old nursey " 
practice be all that is required. A girl in an adjoining bed, who 
came in at the same time as this one, had lost her voice from 
the tumefaction of the vocal cords, yet I did not think it worth 
while to treat her further than by keeping her in bed with hot 
water inhalations and ammoniated salines. But once let inflam- 
mation sink through the mucous membrane of the glottis to its 
submucous tissue, let that become anasarcous, and you see what 
a piteous call for active interference arises ! I say like (Eschylus, 
"you see" the call, because, though the patient has all the 
appearance of screaming loudly, and mayhap is trying to do so, 
no cry reaches your ears. It matters not if the inflammation 
be violent or weak, be rapid or slow — directly it has caused the 
edges of the glottis to swell to the point of not admitting as 
much air as the lungs want — instantly that it has reached this 
point, life is in immediate danger. It matters not what was the 
former state of the patient — the present moment is a present 
and pressing peril — a Samson or a Lazarus equally hovers on 
the edge of the grave. 

In point of fact, the importance of acute laryngitis depends 
not on the degree of injury to life, but on the localization of the 
disease. And hence the value of remedies is closely proportioned 
to the special definiteness of their action on the part affected. 
There may be perhaps in the druggist's shop excellent remedies 
for inflammation, which would act most powerfully all over the 
body of your patient — all over the body of an animal of three 
times the size ; but you do not want just now to act all over 
16 



234 ACUTE LARYNGITIS. 

her body, only on that little spot which stands between her and 
life. Do not run the chance of acting deleteriously on the whole 
person for the sake of a possible benefit to such a minute por- 
tion of it. Do not mistranslate from Hippocrates,. " extremis 
morbis extrema remedia"* and ransack your brains for that 
which is the extremest remedy for this extremely dangerous in- 
flammation ; but seek for that which will get nearest to the seat 
of peril. When this woman came into the ward, she was (as 
described in the report) blue in the face, speechless, incapable 
of swallowing, and breathing without labor and noise. It was 
very obvious that something must be done to relieve her with- 
out delay. But her skin was cold, her pulse was weak and 
quick, and she was worn out by want of food and weariness. 
Wherefore, though I expected tracheotomy would have to be 
practiced, I thought it well to try other measures first, especi- 
ally as there are other measures equally local and equally im- 
portant without being so alarming. I got her warm in bed, 
gave her teaspoonfuls of hot beef-tea and wine, made the air 
damp and soft round the mouth with hot steam, and put four 
leeches on the outside of the trachea. There was some degree 
of relief from this, and the purple hue of the face wore away 
during the afternoon. But the next evening it came back 
again ; and Mr. Young carried out the provisional order for 
tracheotomy. Then the relief was immediate ; the lividity of 
countenance vanished ; she shortly fell asleep, and went on after- 
ward respiring through the tube till such time as the swelling 
of the glottis subsided enough for her to breathe in the natural 
waj ; on which the instrument was taken out. 

Tracheotomy is an alarming operation to hear of or to look 
at, but in reality it is not a dangerous one. Ignorant suicides 
often open the windpipe by cutting their throats right in front ; 
yet they fail to kill themselves, if they miss the great vessels. 

* Few wrong renderings have done so much harm as this, which has led people 
to intrench themselves under the authority of the shrewd Greek, when they 
increase the violence of their remedies in proportion to the violence of disease. 
I have heard M. Chomel do so when bleeding the most severely the worst cases 
of pneumonia ; and " the more syphilis the more mercury " was the rule acted 
upon at the Lock Hospital not many years ago. 



ACUTE LARYNGITIS. 235 

And if a wound under such circumstances of violence does not 
kill, how is it likely to do so when made with the deliberate 
caution of a surgeon ? In point of fact I cannot find on record 
an instance of its being fatal. Patients often die after it, because 
laryngitis is so often complicated with extensive pneumonia, 
croup, diphtheritis ; but I cannot find anything to show that 
tracheotomy has ever hastened the death ; nay, in most even of 
these it seems to have postponed the unfortunate termination. 
Do not, therefore, alarm the patient's friends by speaking of it 
as "a last hope," "a final resource," or by any similar weak 
expression. Doubtless there is danger in the operation — the 
danger of haemorrhage into the trachea ; but there is not half the 
danger your patient's friends are sure to anticipate, and are 
ready to exaggerate, if encouraged by your giving way to weak 
fears. The consequence of this conduct on your part is that 
they beg you to postpone it a little and a little longer, till the 
time has passed for a chance of success. Each minute the throat 
is becoming more swollen and filled with black blood, and there 
is more likelihood of the surgeon's hand being stayed by trouble- 
some haemorrhage ; and haemorrhage is the only thing at all to 
be feared in the performance of the operation. Each minute 
congestive pneumonia is becoming more and more probable ; 
more and more incurable, if already existing. 

The only reason for delay is that of which you saw an in- 
stance in the present patient ; namely, a possibility that the 
excessive urgency of the symptoms may be due to some easily 
obviated external cause, such as cold, weariness, nervous excite- 
ment, hysteria, or the like cause. It was not improbable that 
a patient, chilled with coming to the hospital and sitting in the 
waiting-room, might appear worse than she really was, and that 
warmth, food, and rest might alleviate the pressing danger. 
They did so to a certain extent ; but not so far as to prevent a 
relapse. 

It is not my place to say much about the surgical part of the 
business. I will merely tell you what the physician requires of 
the operator. His requirements are : — 1. That blood shall not 
be allowed to get into the trachea (to secure which the use of a 



236 ACUTE LARYNGITIS. 

simple scalpel, and the waiting for all serious bleeding to have 
ceased before the cartilages are cut, are the best means). 2. 
That the opening shall be large enough to admit of a sufficient 
body of air ; that is to say, it must be capable of being stretched 
to nearly the diameter of the trachea. 3. That the instrument 
inserted should be capable of being kept clean by a nurse, and 
not easily jerked out by spasmodic movements on the part of 
the patient. The ordinary curved double cannula seems to me 
the best. 

So far for restoring the deficiencies of the respiratory func- 
tions. 

But other functions call for care also. You will have seen in 
the case-book that half a pint of warm beef-tea was ordered to 
be thrown up into the colon by enema every three hours from 
the first hour of admission. These patients are usually suffering 
as much from want of food as from want of air. The deficiency 
does not kill them so rapidly as the impediment to respiration; 
nor does it make itself so conspicuous; and for that very reason 
is apt to be forgotten. But observe the convulsive motions of a 
patient with laryngitis on trying to swallow, and you will not be 
surprised that they resist all attempts at feeding by the mouth, 
and that nurses have no heart to force them. The attempt is 
another name for strangulation. Yet if they get no nourish- 
ment,, they are hourly becoming less able to bear up against the 
depressing influence of the devitalized blood, less able to renew 
the injured larynx. This is a matter of great moment, not only 
as regards the present retention of life, but as regards the latter 
prospects of the patient. For the last hundred years people 
have been writing a great deal, more or less wisely, about laryn- 
gitis; but I do not think any one has noticed this important 
part of the treatment since Van Swieten a hundred years ago. 
("Commentary on Boerhaave," vol. viii, sect. 713, ad fin.) It 
seems not improbable, from the details given in published cases, 
that many of those whose immediate danger has been happily 
postponed by the operation, have died of starvation through the 
neglect of this simple measure. 

Whenever you want to administer nutriment in enema, it is 



ACUTE LARYNGITIS. 237 

well to prevent it from running off before being absorbed by add- 
ing a few drops of an opiate. This was done at first in our 
patient's case; but it was not necessary to continue it, as no 
faeces were passed per anum for three days. 

When the powers of life have been so reduced by the deficiency 
of the respiration that the mucous membrane of the intestinal 
canal rejects the food undigested, you may mix pepsine with it; 
and you may appropriately administer tincture of bark and port 
wine. Both were ordered on this girl's card; but little of either 
was given, since within forty-eight hours after the operation her 
pulse had got full and natural. Always remember what I told 
you when lecturing on low fever — wine is an adjunct or help to 
restorative treatment, but if made to take its place, is hurtful. 

When the patients begin to take food again by the mouth, 
you will often find that solids of certain kinds are easier swal- 
lowed than pure liquids. This is noticeable in all kinds of dys- 
phagia; in fact, the embracing of a gulp of fluid by the semi- 
voluntary pharyngeal muscles is a greater effort, and more apt 
to cause spasm, than happens with a more resisting mass. You 
can try this any day in your own throats. You must therefore 
choose as the solid you administer to the patient some one which 
slips down easily, such as the oysters which have been ordered 
for this girl. 

I feel you expect me to say something about two drugs which 
have been recommended in acute laryngitis — antimony and mer- 
cury. I must confess I have never been able to trace any ad- 
vantage from their use, either in cases of recovery or of death. 
I no longer use them, and do not recommend them to you. The 
action of the salts of these metals is to increase destructive meta- 
morphosis, and to lower the force of the heart. By such means 
they certainly do appear to me to have a controlling power over 
inflammation. But it is a power exercised slowly, and at the 
expense of depressing the general vitality rapidly ; so that they 
are peculiarly unsuitable for cases where an effect is desired to 
be quickly produced; for, if enough of them is given to stop in- 
flammatory action in the short time allowed us, a serious lower- 
ing of the vitality follows, extremely dangerous in its more remote 



238 ACUTE LARYNGITIS. 

consequences to patients who have already had to bear the shock 
of being half stifled. 

What I would have you mainly keep in mind in your treat- 
ment of laryngitis is as follows : 

1. If the external and obvious conditions of the patient be 
such that some part of the symptoms may be due to those con- 
ditions, remove them. Warm the surface of -the body; saturate 
with hot steam the air inspired; put on leeches, and hot foment- 
ation to the throat. In special favorable cases, bleed. 

2. If benefit do not quickly follow, perform tracheotomy, or 
get it performed. 

3. If a relapse occur after temporary benefit, every minute 
that the operation is delayed is an opportunity lost. 

4. Food must be sedulously administered, if not by mouth, 
then by rectum. This is especially needful if leeches are put 
on, more especially if you decide to bleed, and still more especi- 
ally than ever if mercury or antimony have been thrown in by 
yourself or others. 

5. Let the restored air for respiration be moist and warm; 
and take care that there is enough of it, by inserting a full- sized 
double cannula in the trachea, and needfully watching the orifice 
day and night, lest it get blocked up by mucus. 

As a contrast to the disease in the larynx inducing such serious 
danger by its locality, but rapidly recovered from by reason of 
the slight morbid alteration which has taken place, I show you 
here a larynx taken this week from the body of a man who died 
of pulmonary consumption. See how extensively it is disorgan- 
ized. The mucous membrane covering all the upper part is 
white, thick, and rough; just below the vocal cords on the right 
side there is a ragged deep ulcer, which has bared the arytenoid 
cartilages, and caused them to become necrosed by killing the 
pericondrium; a piece of the dead cartilage projects into the bot- 
tom of the cavity. There is another superficial ulcer in a cor- 
responding place on the opposite side. Yet here the symptoms 
referable to the larynx were of very little weight. The man's 
voice was indeed hoarse and weak, but not more so than you find 
in most sufferers dying with a very large vomica in one lung and 



•ACUTE LARYNGITIS. 239 

the other filled with crude tubercles, as we found in this autopsy. 
There was a considerable secretion of pus also, and pain in the 
larynx when pressed, but there was no difficulty of breathing, in 
whatever position the patient lay. Consequently no local appli- 
cations were made to the organ. There was no demand for local 
interference, and certainly it would have been useless for the 
lengthening of life. The need calling for restorative treatment 
was the weighty one of chronically deficient nutriment to the 
whole system. The larynx was ulcerated and degenerated for 
the same reason that the kidneys were shrunken and granular, 
and that the whole person was worn down to a skeleton — suffi- 
cient aliment was not absorbed to compensate waste. A despair- 
ing effort indeed we made to supply this by trying to restore 
digestive and absorbent powers to the alimentary canal with 
quinine and iron, and to feed muscle and fat with meat and cod- 
oil. But in vain. Sentence of death had long before gone forth; 
and it was hard to say that the decree was in any measure stayed 
by treatment, however suitable it may have been. My object in 
quoting this case now is not by it to praise the remedial agents 
brought into play, but to draw your attention to the rule, that — 
the immediate danger of diseases is mainly traceable to their 
locality, the final danger to the extent and intensity of the patho- 
logical changes. 

I would lay it down as a law to be observed, that in cases 
where the danger is imminent, the attention of the medical at- 
tendant should be directed to locally active remedies; where the 
risk is more remote, his mind should be turned to those of gen- 
eral agency. Thus in acute laryngitis you are to think of the 
larynx alone, to the temporary neglect of other parts ; in chronic 
laryngitis, you are to consider the general nutrition in preference 
to the local injury. 



LECTURE XIX. 

CAPILLARY (or SUFFOCATIVE) CATARRH. 

Definitions of the disease- — The mildness and severity depend on 
the quantity of bronchial membrane involved — Slighter cases 
essentially of the same nature as the severe cases here brought 
forward — (First case) Uncomplicated bronchial catarrh — 
(Second case) The same arrested on the brink of merging in 
broncho -pneumonia — Treatment by warmth and moisture — 
The same treatment (Mudges) applicable to mild cases — 
Blood-letting — ( Thirdcase) Bronchial catarrh fatal by super- 
vening on lung previously imperfect — Autopsy — Such form 
of fatal disease aptly described as paralysis of the lung — 
Equally fatal to strong as to puny people — Arises from 
exposure to cold air during a catarrh — Banger much in- 
creased by imperfection of lung. 

(Clinical, St. Mary's, January 23, 1864.) 

The late frosty weather has borne its usual crop of many 
severe acute bronchial catarrhs. Three of these came under my 
care last week, and I shall take the opportunity of making a few 
remarks upon the nature of the disease and the treatment re- 
quired by the patient. 

What you see before you is a disease consisting of a rapidly 
occurring congestion of the mucuous membrane of large and 
small. air-passages, resulting in the pouring out of mucus and 
pus, and tending to destroy life by dyspnoea. 

In its slighter forms, and when affecting the trachea princi- 
pally, it constitutes the well-known "cold on the chest" or 



CAPILLARY CATARRH. 241 

" bronchitis"* of the public in general. And when it is prev- 
alent on an epidemic scale, it is called "influenza." In these 
cases it appears to affect almost entirely the trachea and larger 
air-passages, and the oxidization of the blood is hardly at all 
interfered with. When the smaller or capillary bronchi suffer, 
then a serious interference with the aeration takes place, and 
the catarrh becomes, what is well called in old writers, " suffo- 
cative," or in more anatomical phraseology, " capillary catarrh." 

These cases differ from other bronchial catarrhs in the extreme 
sense of suffocation or dyspnoea, quite out of proportion to the 
physical signs elicited by auscultation, or to the cough and 
amount of expectoration. 

Important as the slighter cases are on the score of frequency, 
I cannot find suitable examples for clinical lecturing, for they 
usually are so much better after the seventh day, if there is no 
other disease in the chest, that they seldom appear in the wards. 
I can, however, exemplify by the more severe cases the treat- 
ment ; the principles of which, and most of the details of which, 
are applicable equally to all. 

The. first patient to which I ask your attention is Ellen C, a 
married woman, aged twenty-two, eight months pregnant with 
her second child, who was admitted on the 8th instant, during 
the frost. She is robust and sturdy, and has not suffered any 
inconvenience from her pregnancy. She had a cough for a fort- 
night, but it gave her so little inconvenience that she had not 
laid up till New-year's day, when it got much worse, and was 
accompanied by such shortness of breath that she was obliged to 
keep her bed, and was conveyed from thence to the hospital. 
You saw that the dyspnoea and orthopnoea were excessive, her 
face was congested and the lips livid, and she brought up by 
frequent coughing a small quantity of tenacious sputa, partly 
frothy with large bubbles, and partly consisting of small, round 

* This word is vaguely applied, both by the vulgar and by the profession 
when talking to the vulgar, to any cough with expectoration. I believe patients 
like much better to hear that they have " bronchitis," than to hear that they are 
coughing and spitting ; but I think among ourselves we ought to give up the term 
as the name of a definite ailment; for it has been so much misused that it is too 
late to make it scientifically distinctive. 



242 CAPILLARY CATARItH. 

lumps of tough mucus. The pulse was 120. Auscultation of 
the chest showed the lungs resonant, but filled with whistling, 
cooing, and all kinds of dry rales throughout, so loud, that the 
few moist sounds were seldom audible. She appeared in immi- 
nent danger. 

The whole chest was immediately enveloped in a jacket poul- 
tice of linseed meal, and she was directed to breathe entirely 
through a Mudge's inhaler, kept supplied with hot water. 

On the next day, the 9th, the dyspnoea was much relieved, 
and the pulse had sunk to 100. The same treatment was per- 
sisted in. 

On the 13th the pulse was 88, and she left off the inhalation ; 
on the 16th it was 72; the sputa were more opaque, and she 
breathed easily. The poultice was then discontinued, and a 
blister was applied to the chest. An ounce of decoction of bark 
was also ordered to be taken three times a day. 

This is a case of generally diffused acute bronchial catarrh 
without tendency to pneumonic condensation. 

The second case is that of Edward C, aged twenty-four, a 
bricklayer, now in Albert Ward. He said he had been first seized 
by a cough and pain across the front of the chest on Christmas 
eve. This took him off work immediately, but his breath did 
not get short, as it was when we first saw him, till a fortnight 
had elapsed, and the frost had commenced. Before admission 
he had been attending a few times as an out-patient, and it was 
on the last occasion of his so attending, viz., on the 13th instant, 
that Dr. Markham sent him up stairs to bed, as too ill to be 
allowed to leave our doors. The dyspnoea and lividity of the 
face were not so great as in the last patient, but there was the 
same general diffusion of sibilant rales without dullness on per- 
cussion marked in any region. I say the dullness was not 
marked in any part; but after examination by the stethoscope 
had shown some fine crepitation beneath the right clavicle I per- 
cussed again, and then some of the by-standers thought that the 
upper lobe was not quite so resonant as the other. The tongue 
was white and furred, the sputa copious and frothy, and reported 
to have sometimes a yellow stain. 



CAPILLARY CATARRH. ' 243 

He wanted to go home to fetch "his things," but his request 
was not complied with. He was ordered to be put to bed imme- 
diately, and to be cupped to the extent of six ounces beneath 
the right clavicle, the chest to be enveloped in a jacket poultice, 
and the vapor of hot water to be inhaled. 

On the 16th there was no fine crepitation or dullness on per- 
cussion. On the 20th the sputa had become purulent, and the 
cough alleviated during the day, though troublesome at night. 
He was then ordered two grains of quinine thrice a day, and to 
leave off the poultice, and has continued to convalesce. 

This is a case of acute bronchial catarrh arrested just on the 
verge of resulting in bronchial or catarrhal pneumonia. 

You may observe that the treatment of both these cases has 
been essentially the same as regards the most seriously injured 
part, the bronchial mucous membrane. Moist warmth has been 
kept continuously applied to both the inside and the outside of 
the chest. Moist warmth is the most powerful restorer of 
arrested circulation and vital action that we possess, the safest 
therapeutical engine we know of, because the most direct renewer 
of life. 

Perhaps you may exclaim that this mode of inhalation limits 
the supply of oxygen, which is so much needed for the aeration 
of the blood. I frankly grant that there is less free oxygen in 
warm steam than in cold air, and that therefore certainly less 
oxygen goes into the trachea; but I am not sure that less oxygen 
is absorbed by the pulmonary membrane. For this dilution 
with warm steam softens the tissue, and makes it more apt for 
endosmose ; and even in its immediate action it may cause more 
oxygen to be digested (if I may say so) from the weak, than from 
the strong supply. 

But oxygen (as I have often pointed out to you) is exceed- 
ingly injurious to tissues in the state of partial death which we 
call inflammation, and therefore the limiting, to such extent as 
is consistent with safety, its supply is not a thing to be avoided. 

You may ask whether this mode of treatment be applicable to 
the milder cases, such as you will have more to do with in private 



244 CAPILLARY CATAM&I. 

practice than in a hospital. Yes — there is nothing like the 
§ inhaler for a cold on the chest, for which, indeed, it was first 
introduced by Mudge.* But you will not persuade patients with 
a will of their own to submit to a jacket poultice, unless they 
are nearly as ill as our present patients. 

If there is much thirst, effervescing draughts of citrate of am- 
monia seem to be liked; but when the illness is a serious one 
there is some danger in advising treatment by drugs, because 
sick persons are so prejudiced by habit in its favor, and it is so 
convenient to them, that there is a risk of their neglecting the 
other and more important parts of the advice. 

As soon as the mucus became opaque, you will observe that I 
ordered quinine. Begin your tonics always as soon as you can, 
for they enable more food to be digested, and thus they shorten 
the convalescence. 

In the second case, blood-letting by cupping-glasses was or- 
dered beneath the right clavicle. This was done, because pneu- 
monia seemed to be just commencing in the upper lobe of the 
lung — a very dangerous situation for it to commence in, much 
more dangerous than in the lower lobe, and demanding prompt 
measures as much as the more generally diffused bronchial af- 
fection. 

The third case I shall commence by the post-mortem dissec- 
tion. On Wednesday, some of you saw the examination of the 
body of a woman aged about forty, externally in good condition, 
and not emaciated or presenting any aspect of chronic ailment. 
The removal of the ribs disclosed the right lung contracted very 
much, and clothed as to its lower part with a smooth white 
leathery coat, not adherent to the walls of the chest, and but 
slightly to the lung, though it had bound the lobe together in its 
contraction, and had caused atrophic degeneration of its tissue. 
It was probably the remains of old hydrothorax, for which she 
was in St. Mary's about three years ago. The upper lobe of the 
same lung was not much better fitted for receiving air, for it 

* " Radical cure for a recent catarrhous cough, with a chapter on the vis vitge, 
&c." Second edition. 1779. 



CAPILLARY CATARRH. 245 

contained old and contracting chalky tubercle, and a vomica of 
ancient date as big as a chestnut. In the left lung there was no 
tubercle or consolidation or signs of pleuritic disease; but the 
whole substance was doughy, retaining the marks of the five 
fingers when the hand was pressed upon it. The tissue was not 
nearly so crepitant as it should be, and it was black with venous 
blood. Some parts seemed more decidedly emphysematous. 
The trachea and bronchi were deeply reddened and dry, no pus 
exuding, as it so often does, from their orifices when cut across. 
Heart and abdominal viscera were of quite normal appearance. 

This woman was in the hospital but four days, and was too ill 
for us to learn much from her during life. She was a quiet 
gentleman's cook, and, though habitually subject to cough and 
short-winded, had been able to do her moderate work somehow 
till the arrival of our late severe weather. That laid her up, and 
in a week reduced her to the condition in which she was on ad- 
mission, namely, hardly able to breathe even when propped up in 
bed, with the face livid, and the purple blood-shot eyes starting 
out of their sockets. I do not think she had any expectoration. 
Dry cupping and poultices did no good, and she was unable to 
foment the bronchi with Mudge's inhaler. As, from the reso- 
nance on percussion over the cardiac region, I had suspected 
there was^a good deal of emphysema, I gave her some lobelia 
and ether, but I could not perceive that it brought any relief. 

There is more instruction to be gained from the appearances 
after death. I dare say some of you can call to mind that ter- 
rible February during the Crimean war, when the stern sovereign 
of our stern enemies was suddenly death-struck, while actively 
engaged in his patriotic duties. Few can forget the ghastly 
satire, too bitter for us even at that bitter time, with which 
" Punch's" artist hailed the event; and medical men remember 
how the public was puzzled by the bulletin of the German phy- 
sicians, who announced the death as due to " paralysis of the 
lungs." By this unusual but not inapt term they intended to 
designate that complete obliteration of function which we see in 
such lungs as these; and the Emperor's illness was of the same 
nature as I am quoting three examples of to-day, namely, inflam- 



246 CAPILLARY CATARRH. 

mation — a partial death — of the bronchial mucous membrane, 
resulting in obliteration of function. It arose, too, under the 
same circumstances of exposure to severe dry frost during a 
catarrh. 

People were surprised at the rapid sinking of a man so re- 
markably muscular and strong as our gallant enemy. Eut I 
happened at that very time to be called to see a country clergy- 
man of large frame and great height, who sank in the same way 
from fatal bronchial catarrh, brought on by exposure during a 
cold on the chest. So that I felt less surprise than others. And 
I am rather disposed to think that big burly people, once severely 
smitten, yield to the disease even sooner than others. 

I have noticed, in the second case, how anxious I was to pre- 
vent the man from going out in the cold after we had once got 
him up into the ward. My reason was, a feeling of the extreme 
danger not only of the extension of the catarrhal state which is 
brought about by cold air, but also of the penetration of the 
inflammation to the tissue of the lung (lobular or catarrhal 
broncho-pneumonia). Of the two ways by which inflammation 
penetrates to the lungs, from the inside or the outside, the former 
is much the worst. I have no doubt but what it was the unfor- 
tunate independence of control, which is a necessary part of sove- 
reignty, that destroyed the Emperor. He was determined to go 
on with his duties, come what might, and nobody's will was strong 
enough to say, "We will not let you." 

Any disease which has previously limited the area of available 
lung increases very much the danger of capillary catarrh. In 
the patient who is my present text the atrophied state of the 
lower right lobe, the ancient tuberculosis of the upper, and the 
possibly prevenient emphysema of parts of the left lung, took 
away her chances of renewed life. Had I been aware of them 
all, I should have given a still more unfavorable prognosis than 
even the symptoms made me give. 

In the last sentence I applied the epithet "possibly preve- 
nient" to the emphysematous state of the pulmonary tissue. I 
did this because the patient had given us during life some broken 
history of shortness of breath affecting her for a considerable 



CAPILLARY CATARRH. 247 

period, and it would be difficult to say that this degenerated 
condition of the lung membrane had not existed as its cause. 
But I said "possibly," because in fatal cases of capillary catarrh 
emphysema is so often found, even in patients previously healthy, 
that it certainly must be a consequence, and not the origin of the 
complaint. This is especially the case in infants, whose lungs, 
when they die of bronchial catarrh or of broncho-pneumonia, 
are almost invariably highly emphysematous ; a state of things 
which their age and previous good health show to be capable of 
very rapid development. 



LECTURE XX. 

PNEUMONIA. 

Three cases of 'pneumonia — 1. Frank, uncomplicated double 
pneumonia in a temperate man, with excessive dyspnoea — 
Cured with venesection, jacket poultice, continuous feeding, 
and wine. 2. Pneumonia of upper and loiver lobes of one 
lung, very slight in the other lung, in a broken-down old 
man — Cured with cupping, jacket poultice, continuous feed- 
ing, and wine. 3. Congestive pneumonia of lower lobe in* 
typh-fever — Cured with half -jacket poultice, cupping beneath 
scapula, continuous feeding, wine, and bark — Commentary — 
Pathology of pneumonia — Importance in proportion to quan- 
tity of tissue involved, not to stage of progress — Hence the 
value of a ready and quick means of checking its progress — 
Blood-letting — Action of it— General and local compared — 
III effects of loss of blood — Mode of judging of the necessity 
for it — Compensation for it — Poultices — Their action — Es- 
pecially adapted fdr infants — How to make them — Alcohol, 
when required — Effect of position in the pneumonia of typh- 
fever — Blood-letting — Purgatives — Blisters — Antimony 
and mercury. 

(Clinical, St. Marys, May 10, 1862.) 

There have been three patients under my care in the Albert 
Ward for males this week, to whom I have drawn jour attention, 
as illustrative of the most co|nmon phases under which we have 
to treat pneumonia in the adult. 

No. 1 is a case of frank, uncomplicated inflammation of the 
pulmonary tissue. 



PNEUMONIA. 249 

R. G., aged twenty-one, a very steady and temperate police- 
man, well made, robust, and never previously ill, was on April 
12 taken with severe rigors, followed by a dull pain in the side, 
and cough. He got worse under treatment from day to day, and 
on the 18th was so alarmingly ill that his friends carried him to 
the hospital. I saw him shortly after he was put to bed, and 
certainly felt that they were justified in their alarm. The respi- 
rations were abdominal and were thirty-six in the minute ; he 
struggled and gasped for breath; his lips and tongue were livid; 
the pulse was very quick and small, but the heart beat strongly 
in spite of its great rapidity. The expectoration was copious and 
glairy, of a deep tawny color, and with a few small striae of blood 
in it. 

The whole of the ribs on the right side were motionless during 
inspiration, while the movement of those on the left front was 
very visible. In the upper half of the upper right lobe, and in 
the lower right front, there was fine crepitation and comparative 
dullness on percussion. Beneath the right shoulder-blade the 
dullness was more absolute and there were coarse rales. Beneath 
the left there was fine crepitation. It was obvious that active 
inflammation raged throughout nearly the whole (if not quite 
the whole) of the right lung, and in the lower lobe of the left, 
and that it was most advanced in the back part of the right side. 
At most a third of the pulmonary tissue was in working condi- 
tion, so no wonder that exaggerated puerile breathing was heard 
in that third, and the ribs were heaved in an extraordinary 
manner, where heaved at all. 

The patient was bled to three-quarters of a pint from the arm, 
took eight ounces of port wine during the twenty-four hours, and 
beef-tea every two hours, and had his chest completely enveloped 
in a thick hot linseed-meal poultice. He was ordered also three 
effervescing draughts of citrate of ammonia* daily. 

I am told that relief began immediately after the venesection. 

* Ammonice sesguicarb , ^iss, Acidi citrici, ^iss. This is so refreshing to the 
feelings when one is tired or ill, that I think it must be a directly constructive 
drug. Both the carbonic acid and the ammonia take part in forming the sub- 
stance of the body. 
17 



250 PNEUMONIA. * 

At all events, next morning there was a great improvement, the 
breathing being much easier, the patient expressing himself as 
"stronger," and the sputum being but slightly tinged with brown. 
On the succeeding day there was a further step gained, and the 
pneumonic hue had disappeared altogether from the mucus ex- 
pectorated. However, in the parts of the right chest in front 
whence I raised the poultice temporarily for examination, viz., 
an inch beneath the collar-bone and an inch beneath the nipple, 
the dullness on percussion seemed very decided. But I will not 
allow myself the enticing task of describing a patient's daily 
progress toward health : suffice it to say, that on the 26th, eight 
days after admission, the effervescing draughts were exchanged 
for decoction of bark, and that to-day, May 10, he goes out well. 
The respiration is quite natural, percussion and expansion normal 
in the upper lobe and back part of the lower lobe recently in- 
flamed; but there still remained yesterday some little crepitation 
mixed with the healthy breathing, and slight comparative dull- 
ness below the mamma. I dare say it is gone now. 

No. 2. — Hugh J., aged sixty-three, porter at a charitable in- 
stitution, a respectable man, but not quite free from a suspicion 
of petty tippling, had an attack of pneumonia of the lower half 
of the left lung under my care about this time last year, from 
which he entirely recovered so far as the local symptoms were 
concerned, but he has looked older since. At the beginning of 
last week, April 28, he was again taken ill. I saw him at his 
home on the 2d of May, and sent him up to this hospital. On 
the right side the whole lower lobes and the greater part of the 
upper lobe were consolidated. In the upper lobe, fine crepi- 
tations were heard throughout. There was also some fine crepi- 
tation in the back part of the left lung. His tongue was thickly 
furred and clammy, his hands tremulous, and his manner excited. 
There was also occasional delirium. The pulse was large, short, 
and empty — such as is usually found with the inelastic arteries 
of old age. He was cupped that day to six ounces on the cardiac 
region, and on the morrow to the same amount beneath the right 
clavicle. The chest was completely enveloped in a jacket of lin- 
seed poultice. He was ordered eight ounces of port wine, food 



PNEUMONIA. 251 

every two hours, and three effervescing draughts daily of car- 
bonate of ammonia and tartaric acid. 

May 5. — Pulse 128. On the 4th there was considerable diar- 
rhoea, which ceased on the following daybreak, after a small 
dose of Dover's powder. 

May 6. — Less crepitation in left upper lobe, but dullness on 
percussion, and coarse mixed with fine crepitation in right upper 
lobe. Sputa have been for the last three days very abundant, 
and of a deep rusty color. 

No change in the symptoms, except the gradual diminution in 
quickness of the pulse, is noticed till to-day (the 10th), when the 
sputa are darker and more like prune-juice, but showing signs of 
improvement by having some specks of opaque purulent matter 
in them. The tongue is also a little moist, and only gets quite 
dry after sleep. He may be considered to have turned the corner 
in his progress toward recovery, and I have no hesitation now 
in pronouncing a favorable prognosis. No change has been made 
in the treatment. 

[On May 16 he began to take bark and ammonia. On the 
morrow the expectoration is noticed to consist of clear mucus for 
the first time since his admission, and he left the hospital to re- 
turn to his place on May 30. Case-book 161, p. 187.] 

No. 3. — John L., aged seventeen, was brought here from a 
house where his mother and sister have just died of '"typhus- 
fever," according to the account of an aunt who came to see him. 
He was taken ill on April 20, and when admitted on April 23, 
was as unfavorable a subject to look at as I ever saw at that 
early period of low continued fever. There was complete pros- 
tration and constant delirium, the tongue was clammy and tremu- 
lously protruded with great difficulty from the dry lips, the pulse 
120 and small, the skin hot and dry. The eyes were bloodshot, 
and on the front of the body were from thirty to forty fever spots 
of various hues, some slightly raised and inclining to rose color, 
some livid, some completely purpuric and not changed by pres- 
sure. I mention these details because it is such cases of typh- 
fever, where the hgematine of the blood is apparently so much 
poisoned, that are aptest to be accompanied by inflammation of 



252 PNEUMONIA. 

the lungs. He was treated in my usual way with hydrochloric 
acid and tepid sponging, and was going on as usual very well 
till May 3, when some fine crepitation and dullness on percussion 
were found in the lower lobe of the right lung, accompanied by 
slight cough, but without expectoration. On the 4th he was 
cupped beneath the right scapula to four ounces, a poultice was 
applied over that part, and he was directed to be kept turned 
over on the left side. On the 7 th the breath-sounds were healthy 
except a little coarse crackling mixed with vesicular breathing, 
such as is generally found in typhous patients ; the percussion 
was normal. The tongue and other muscles were scarcely, if at 
all, tremulous. He is now going through a rapid convalescence 
under bark and wine, and in a few days will doubtless be able to 
stand on his legs. 

While speaking of this case, and before I enter upon the treat- 
ment of pneumonia, I will make one observation to you on the 
importance of the diagnosis of the cause of dullness on percus- 
sion in acute fevers. In this instance there was no doubt about 
the prognosis of the rapid termination of the congestive inflam- 
mation. But you must not say the same on every occasion of 
finding the pulmonary tissue condensed in fever. A man will 
leave the hospital for a distant home in a few days, who has re- 
covered very slowly from an attack of spotted-fever rendered 
severe by dysenteric diarrhoea. He has had at the same time 
primary syphilitic sores and a bubo, and had been taking mer- 
cury;* so that his tedious convalescence was quite accounted for 
by his previous history. Besides this, during the time he was 
laid on his back, I had found a considerable amount of consolid- 
ation about the middle of the right lung, and at the apex crepi- 
tations. As at that time he was not well able to give an account 
of himself, I was inclined at first to set this down to pneumonia, 

* I would remark in passing that this man's dysenteric diarrhoea (i. e. pain in 
the bowels with fever and blood-stained stools) came on very early in the ill- 
ness, namely, on the third day, although the usual tendency of continued fever 
this year is by no means dysenteric. He was under the influence of mercury at 
the time. The action therefore of that drug is at least not preventive of bowel 
affection. Is it curative? 



PNEUMONIA. 253 

to treat it as such, and anticipate its disappearance. You saw, 
however, that this morbid state remained unaltered when I ex- 
amined him for his discharge, and it seemed to me by his tale of 
former winter cough and haemoptysis to be due to chronic tuber- 
cle. He will probably become consumptive some day. Learn 
from this case to take good heed before you hail a consolidation 
of the lung in fever as merely congestive. 

Now to return to the* text of to-day's lecture. 

In pneumonia a most truly vital organ is smitten ; and so far 
as the disease extends, the destruction is total. A consolidated 
or even congested piece of pulmonary tissue is absolutely power- 
less to fulfill its duties, and yet that those duties should be ful- 
filled is essential to animal life. It is easy therefore to under- 
stand that the gravity of the pneumonia is in direct proportion 
to the quantity of lung involved. The degree or form of the 
inflammation or condensation is of much less weight, so far as 
immediate danger is concerned, than the extent of tissue over 
which it is spread. 

Hence comes the importance of having some ready and effectual 
means at hand to check the march of the inflammation into fresh 
parts. If we can do this, we contribute more certainly to renew 
the patient's life than if we regulated, however favorably, the 
progress of it in already affected places. No means is so readily 
applied, so immediate in its operation, as blood-letting. Its action 
has not to be waited for, like that of drugs in medicinal doses, 
but begins at the moment of application. That is a great point 
where time is so valuable. I believe also that it is the most 
active of the agents at our disposal, and that rightly used it is 
the saving of many a life in pneumonia. But at the same time 
I would have you clearly understand that "this is not a bow for 
every man's drawing" at every time, that though it is most rapid 
and active for good, it may be also most rapid and active for 
evil, and that foolishly and thoughtlessly used it has caused 
many a death. 

The good done by blood-letting in pneumonia is mechanical. 
The pathological state which asks its aid may be drawn as fol- 
lows: by the temporary death of a portion of the lungs the 



254 PNEUMONIA. 

blood cannot be quickly enough passed onwards through their 
tissue ; it can run freely as far as the right side of the heart, but 
there it is stopped; the throng pressing onward from behind 
makes matters worse, and thus the balance between the venous 
and arterial heart is destroyed. . You can feel the apex of the 
organ beating strongly against the ribs, the muscular action 
being excited by the presence of an unwonted amount of venous 
blood ; yet the artery at the wrist is at the same time striking 
your finger with a weakened force. Take away some of the 
blood from the veins, and the balance is restored; the pulse be- 
comes in technical phrase "freer;" that is to say, the heart being 
relieved of the undue crowd in the right side, is not checked in 
its contraction, but is able to clinch upon its contents, and sup- 
ply them steadily to the arteries. 

Judge then of the fitness of this treatment by the balance 
between the heart and the arteries. If the apex of the former 
organ strikes strong, while the pulse at the wrist is oppressed, 
act freely and confidently. If,- on the contrary, the ventricles 
are weak, while the pulse is large and rapping, be cautious in 
what you do, and if you draw blood at all, let it be by cupping 
the chest. 

The advantages of general and local blood-letting are of essen- 
tially the same nature, though the operations differ somewhat in 
degree, and are diversely applicable. Where the patient, previ- 
ous to his current illness, was in vigorous health, actively digest- 
ing his food and actively renewing his tissues, he will bear and 
easily repair the abstraction of a good large quantity of blood. 
And a good large quantity of blood is most conveniently drawn 
from the arm. To get the full advantage of the remedy, you 
would practice venesection. But if the pneumonia has come on 
a person previously an invalid, or in weak health, you fear for 
the possible bad consequence of your treatment, and you cast 
about for some means of getting the greatest advantage out of 
the least loss of blood. This is obtained by cupping on the 
region of the heart. Your four or five ounces taken from thence 
in a delicate invalid seem to produce as much corresponding effect 
as the loss of twelve or fourteen let from a vigorous man's arm. 



PNEUMONIA. 255 

Or, if it be more convenient, you may put on leeches. As a 
rule, however, I prefer cupping, for you can easily graduate the 
depth of the cuts, so as to be able to stop them with ease ; whereas 
leech-bites will sometimes go on oozing for a long time, unper- 
ceived, into the poultice, which (as I will instruct you presently) 
is to be put round the chest. 

Another advantage of local blood-letting is the relief it gives 
to pleurisy. There are few cases of pneumonia where there is 
not some amount of inflammation of the serous coat of the lungs 
or ribs ; and though the feeling of oppression in the chest over- 
tops and deadens the stitch in the side, which would otherwise 
be felt, yet there is no doubt but that the pleurisy adds to the 
distress, and the relief of it is no mean matter. Local blood- 
letting is for this purpose more effectual, in proportion to its 
quantity, than general. 

You will find some authors try to ground rules about blood- 
letting in pneumonia on the supposed degree of consolidation of 
the pulmonary tissue. These rules are practically inapplicable. 
They say you should bleed so long as you know that the lung is 
in its first stage of condensation (i. e. congestion), as proved by 
fine crepitation and incomplete dullness; and that you should 
not bleed after it has once become completely consolidated so 
as to admit no air into the finer bronchi, a state declared by the 
sound of coarse crepitation and complete dullness. Such a rule 
is quite useless at the bedside, and will often prevent your em- 
ploying active practice in cases where it is urgently called for. 
In the first place, in a majority of cases fine crepitation is masked 
by the mixture of coarse crepitation, produced by the presence 
of catarrhal mucus in the larger bronchi, especially in the catar- 
rhal pneumonia of the young. If you wait till you can distinctly 
hear fine crackles, you will wait too long. Moreover, the dull- 
ness of congestion is not necessarily incomplete; as you may 
satisfy yourselves by examining recent congestion in continued 
fever, which is often very absolute, though so transitory that a 
mere change of position may remove it in twenty-four hours. 
Then again, a slight collection of serum in the pleura may make 
the lower lobe dull at the very outset, and prevent your bleed- 



256 PNEUMONIA. 

ing at a very early stage, if you were to follow the rule I quoted. 
But the most serious objection to the rule is, that you may have 
all stages of partial tissue-death going on at the same time ; one 
lobe, or one part of a lobe may have advanced even to yellow 
hepatization, while another part is just beginning to enter into 
red hepatization, that is to say, into a condition which by gen- 
eral consent is most capable of benefit from blood-letting. 

Your best guide to the necessity will be the dyspnoea. If your 
patient is inhaling laboriously from twenty to thirty times a 
minute, straining convulsively the muscles of inspiration, you 
may know that the congestion is recent and is spreading to new 
spots ; and you will act wisely by endeavoring to stop it. And 
your best check against excess will be the balance of the heart 
and arteries. 

Remember that in letting blood you are wielding a dangerous 
weapon. While from a mechanical point of view nothing can 
equal the aid it gives, at the same time its more remote or phys- 
iological action is baneful. If you gain the inestimable boon of 
a restoration of balance in the circulation, and a consequent 
relief of dyspnoea and renewal of life in the lungs, you must not 
complain if some evils attend the process. The mere loss of so 
much "liquid flesh" is in itself an evil, but a minor one; of 
greater import is the increased proportion of the effete fibrin 
and water which it induces, the diminution of solid haematine, 
and the consequently diminished power to bear up against the 
destruction, however temporary, of so much pulmonary sub- 
stance. 

Remember also now what I told you about bleeding in a 
former* lecture on anaemia and blood-letting — be careful to 
supply material in the place of that which you are taking away. 
Let the patient be fed with beef-tea or milk every two hours, 
just as if he had typh-fever. This is to be done in all severe 
cases irrespective of other treatment ; but I mention it next to 
the bleeding, to remind you of the close connection which there is 
between the two, between exhaustion and supply. It contributes 

* " Former" in respect of time of delivery. It comes later in this volume. 



PNEUMONIA. 257 

as much, to your success, whether you elect to bleed, or whether 
you do not. 

I come next to another direct restorative about the use of 
which also anywhen and anywhere you need have no manner of 
hesitation. You can always, without any exception of age, sex, 
condition, cause, or complication, follow a treatment to which I 
attribute more power of saving the lives of pneumonic patients 
than to any other, and which you see me apply in all cases ; I 
mean the wrapping up the chest in a large bath-like poultice. 
The action of warmth and moisture on animal tissues tends 
directly to increase their vitality. You may see with the naked 
eye a healthy surface of skin under their application renew its 
life ; it empties itself quicker of its pale, livid, venous blood, and 
glows with a fresh access of the bright arterial stream ; it swells 
up elastically with fresh juices ; it is more delicately sensitive 
when used for the purposes of touch ; at the same time it feels 
no pain, but on the contrary an exquisitely pleasurable calm. 
You cannot see with your eyes this renewal of life in internal 
organs, but you may infer that what takes place in one tissue 
takes place also in another, with modifications of course de- 
pendent on distance and other difficulties of application. And 
you may infer it also in pneumonia from the results ; for you 
find the dyspnoea diminished, the breath being easily drawn in 
spite of the weight of the poultice ; the hot fevered skin becomes 
moist and active, and soon the ribs begin to move again, and air 
is readmitted into the hitherto paralyzed lung tissue. These 
effects are the most strikingly shown in the case of infants, 
whose thin chest-walls a*e rapidly and efficiently penetrated by 
the influences of the poultice, and in whom also this remedy is 
the only one really safe and invariably necessary ; for they 
cannot afford much loss of blood. I cannot speak too strongly 
of the importance of your adopting it, and letting all other 
treatment be passed over rather than this. 

The poultice is best made of linseed meal, because that keeps 
moist the longest. It should be spread half an inch thick on a 
cloth or flannel as broad as the circumference of the thorax. If 
any portion of the upper lobes be inflamed it is essential, and 



258 PNEUMONIA. 

even if only the lower lobes are inflamed it is prudent, that the 
poultice should be deep enough to cover the whole chest from 
the collar-bones to the hypochondria. Lay the patient in it on 
his back, and fold it across the front till it meets. In adults it 
will usually keep in place of its own accord ; but in children you 
should have a tape stitched on in front, and a tape behind which 
you can tie over each shoulder in the manner of a shoulder- 
strap ; otherwise the little prisoners wriggle out of their soft 
breastplates. When once you have got this jacket poultice in 
situ, keep it there, and desire the nurse, on pain of dismissal, 
never to take it off until another hot one is ready to go on. 

In low fever the continuous poultice somewhat stands in the 
way of the cool sponging. But in practice this last part of the 
treatment of fever becomes less necessary at the period when 
congestion and pneumonia occur ; the skin has then become 
cooler and more active. Besides, the poultice often takes the 
place of sponging by softening and suffusing with a gentle per- 
spiration' the whole body. I have often heard pneumonic pa- 
tients grumble ac the way in which the moist warmth makes 
them sweat. Of course they were comforted when they were 
told it did them good. 

Alcohol, especially in the form of port wine, is very useful in 
treating pneumonia. Even in hearty, temperate persons, when 
you are going to bleed, it is desirable to give a little, as was 
done in Case 1. A glass of hot negus before the operation, 
makes it safer. And whenever you observe the nervous system 
prostrated by the extent of the disease, so as to produce tremor 
of the hands, quivering of the tongue, delirium, dry brown 
tongue or a tendency thereto, throw in a little wine from time 
to time. Old persons, especially in the upper classes, who have 
been used to good living, and persons of all ages who have in- 
dulged too freely in alcoholic liquids (as Case 2), may begin wine 
immediately ; you need not wait for any symptoms as above 
described. In children, on the other hand, it is rarely required, 
and they get well quicker without it. 

In the administration of alcohol in any form, a rule directly 
opposite to that which governs the giving nutritious food should 



PNEUMONIA. 259 

be observed. The quantity considered necessary, in proportion 
to the previous habits of the patient, should be given in one, or 
at most two doses during the twenty-four hours. The frequent 
repetition of small doses has appeared to me injurious, or at all 
events less beneficial than the same quantity in a few larger 
doses.* 

In the pneumonia of low fever position is of great importance. 
As long as the walls of blood-vessels retain their natural elas- 
ticity they are able to bear up against the gravitating force 
acting of course on the blood as on all matter ; but when their 
life is lowered in disease, the elasticity is the first vital property 
that suffers, and the blood is then drawn toward the lowest part 
of the viscus. This is especially the case in low fever. Lay 
the patient, therefore, on the opposite side to that affected (as 
was done in Case 3), or even on his face for a time, if both sides 
are affected ; and thus the very force of gravitation which you 
feared as an enemy, becomes a friend, by withdrawing the con- 
gestion from the weaker point. 

This boy was cupped on the side. You need not shrink from 
taking a little blood in low fever, where an important viscus 
requires it. A large portion of the vital fluid you take away is 
poisoned and dead already, and unfit for the purposes of life, so 
that you are not robbing the patient to the' full extent of the 
quantity drawn. You saw the lad was much more lively after 
his cupping than before. It is better to bleed locally than gen- 
erally, because local benefit is expected from it, and not general, 
and the dyspnoea is seldom very urgent. 

I always shrink from giving purgatives in pneumonia. My 
reason is because I have observed that patients who have 
diarrhoea at the same time generally do very badly. And if 
natural diarrhoea does harm, I infer that artificial diarrhoea does 
harm also. I prefer to produce constipation by opiates, where it 
does not already exist. If the rectum gets blocked up with 
faeces, it is easy to wash it out with warm gruel. 

Blisters have seemed to me to do harm in a few cases where I 
have known them to have been employed before the patients 

* For reasons see Lecture XLIX. " On the use of alcohol." 



260 PNEUMONIA. 

came under my care. It is usually non-medical persons who 
put them on, under the general idea that they are good for a 
cough with pain in the chest. 

I am afraid I must equally condemn antimony and mercury, 
drugs formerly often administered in pneumonia. When I used 
them I was often and often driven to leave them off on account 
of bad symptoms due to their agency, and in prosperous cases I 
always felt doubtful if the success could be fairly traced to them. 
Looking now at disease by the light of the theory of cure which 
I always set before you, this failure is rationally explained. The 
drugs named are pure destructives ; the disease is also one of 
pure destruction ; there are in it fewer of the phenomena of 
retention than in any other, and none of the insertion of a 
morbid poison in the system. The gain then which destructive 
drugs can bring is infinitesimal, and the risk infinite. They do 
more harm than bleeding by their physiological action, without 
any of the mechanical recommendations of that remedy. They 
merely aid the disease in its worst effect. 



LECTURE XXI. 

PNEUMONIA. 

Record of six cases during recess — (1st Case) Caution about 
blood-letting — (2c? Case) Pneumonia of upper lobe in third 
stage, viz., of abscess — Repeated attack of pneumonia during 
convalescence, fatal to this patient — Post-mortem examina- 
tion — Remarks on treatment — Cause of second attack — (3cZ 
Case) Pneumonia in Bright' s disease cured — State of lung 
afterward — (4th Case) Pneumonia in measles — Catarrhal 
pneumonia — (5th Case) Pneumonia treated ivith opium — 
When opium is desirable — Reduplicating pulse — (6th Case) 
Pneumonia in a pregnant woman treated with opium — Re- 
marks on vomiting in pregnancy — Additional eases present 
in hospital — (7th Case) Early occurrence of pneumonia in 
typhfever — (8th Case) Double pneumonia in a fatal ease of 
delirium tremens — (9th Case) Double pneumonia slowly pro- 
gressing from one lung to another — Pleurisy also on one side 
— Pood in convalescence — Mode of recovery of consolidated 
lung — (10th Case) Catarrhal pneumonia — Severity of symp- 
toms at first, and rapid relief — Treatment by poultices and 
local blood-letting — (11th Case) Double pneumonia in a man 
of drunken habits — Also catarrhal, and therefore distin- 
guished by the severity of the symptoms at first — Treatment 
with opium, poultices, and cautious cupping — Delirium — 
Wine — (12th Case) Pneumonia morientum in death from 
other causes — Recapitulation. 

(Clinical, St. Marys, May 2, 1863.) 

I believe complaints are sometimes made against clinical 
lecturers, that they do not sufficiently interest their pupils by 



262 PNEUMONIA. 

presenting for consideration strange and rare cases. I shall be 
deeply grieved if my exertions cease to .arouse your attention ; 
but I must at once say that it is a matter of conscience with me 
to set before you a subject for instruction in the lecture theater, 
and for the less formal bedside teaching, primarily and mainly 
those forms of disease which you will most commonly have to 
treat in after-life. The time I shall endeavor to allot to each will 
be proportioned as closely as possible to the frequency of its 
occurrence. I believe that to be the most accurate measure of 
its importance. to the public, and therefore to medical men. 

Since I last addressed you before the Easter vacation there 
have been six cases of pneumonia under my care in the hospital, 
which are sufficiently ordinary examples of the disease to present 
several points of practical instruction. 

I. Caroline D., though a sexagenarian, has never been seriously 
ill before, and was quite well till the 3d of April, when she sud- 
denly lost her appetite and felt ill all over. She had a bad cough, 
but no local sensation of pain in the chest or elsewhere. She was 
admitted April 10. Her pulse was 104, empty, sharp, and weak. 
The inspirations were thirty-six in a minute. There was dullness 
on percussion and fine crepitation of the lower right lobe, and 
some fine crepitation mixed with healthy breathing in the lower 
left lobe. She was ordered — 1^ Ammonia sesquicarbonatis gr. 
iv. JEtheris TT|xv. Misturse Camphoree §j ; alternd qudque 
Jiord. Hirudines xii infra scapulam dextram, et postea cata- 
plasmata assidue applicentur. 

The signs of inflammation did not further spread, but the right 
lower lobe became consolidated, so that on the 18th bronchial 
breathing and dullness on percussion is noted in that situation. 
On the 22d the pulmonary tissue began to become pervious 
again, and there was the well-known " crepitation of return" in 
the place before consolidated. The medicine was changed for a 
mixture of squill and senega, but she complained that this 
nauseated her, and it was left off, and no drugs given at all. 

You may perhaps be surprised that in treating a patient so old 
as threescore, and where the pulse was empty, sharp, and weak, 



PNEUMONIA. 263 

I should have ventured upon taking blood. But I had calculated 
here upon receiving valuable aid from the digestive organs. Like 
most persons who have lost appetite from severe febrile disorder, 
she had eaten scarcely anything for several days. I calculated 
therefore that a continuous animalized diet, such as beef-tea and 
milk every two hours, would more than replace a moderate loss 
of blood, and I should have been sorry to miss the advantage 
which its local application confers by staying the progress of 
congestion toward condensation in the pulmonary tissue. 

In old age it is quite true that the detraction* of blood does 
more harm than in youth or middle age, because there is less 
strength to spare ; but at the same time it does more good than 
in youth or middle age, because of the tendency in later life 
which congestions have to increase, and to increase so very 
insidiously, and to recur when checked. So you must not forget 
what a powerful weapon you are wielding, and how double must 
be your caution in old age. 

The second case of also an aged woman, is in point here, 
although a fatal one. 

II. Mary McK., admitted February 27. She did not know 
the date of her birth, but looked upward of sixty. She had been 
quite well of late years till three weeks previously, when she had 
slept in a damp bed after being exposed to much heat as a 
washerwoman. This was immediately followed by rigors, feeling 
of complete prostration, and loss of appetite. I fear she had but 
little care taken of her during the height of the inflammation, 
for she seemed on admission to be almost moribund, and abso- 
lutely refused food. On examination of the chest the upper lobe 
of the right lung was found completely condensed, absolutely dull 
on percussion, with tubular breathing and coarse mucous rales, 
and in some places coarse bubbling. There was but little cough, 
but copious green expectoration. 

Prom the localization of the part affected in the stethoscopic 
examination, it was very doubtful whether this were not a case 
of senile tuberculosis. But the suddenness and recency of the 
invasion were against that diagnosis, and I inclined to think it 
the third stage of inflammation of the upper lobe. 



264 PNEUMONIA. 

The diagnosis made but little difference in the treatment ; for 
I gave her quinine and cod-liver oil, much as I should have clone, 
had it been determined to be tubercular phthisis. 

We had great difficulty about the patient's food ; she said, on 
admission, she could eat nothing, and at first she persisted in 
eating nothing voluntarily, the nurse having to use actual force 
in giving her tye beef-tea and milk which I had insisted upon 
her swallowing. She improved considerably under this treatment 
by three weeks after admission. On the 18th of March I found 
there was not the same extent of dullness below the right collar- 
bone, but there was still very considerable dullness and very 
coarse low-toned bubbling rales. She was recovering also her 
flesh and strength, and was capable of being intrusted so far 
with her diet that she was allowed to be dressed and have ordi- 
nary diet and porter with the other patients. She seems to have 
freely used her permission to get up, and to have fatigued herself 
very much on the 19th and 20th. On the morning of the 21st 
she had a shivering fit, she lost her appetite and became feverish, 
and had severe pain in the head. There was then a good deal 
of typh-fever in the wards, and it seemed very much as if she had 
caught that disease. So she was given a couple of emetics, con- 
tinuous food, wine, and hydrochloric acid. But on the 26th my 
attention was drawn to her lungs by the expectoration of orange- 
colored sputa in considerable quantity. Her tongue had become 
dry and brown in spite of the wine, and yet there was none of 
the nervous symptoms (such as obtuseness of the sense, delirium, 
or tremor of the muscles) which one looks for in cases of typh- 
fever. An examination of the chest detected the serious fact that 
the diagnosis had been too hasty, and that the symptoms really 
were due to pneumonia. The whole of the right lower lobe was 
already impervious to air from recent consolidation, and there 
was fine crepitation also in the left lower lobe. Half a dozen 
leeches were put on the latter side, and a jacket poultice over 
the whole chest : bark and wine were freely given : but little 
hope could be entertained of preserving life. She survived just 
long enough for the expectoration to become purulent, but died 
on the 6th of April. 



PNEUMONIA. 265 

At the post-mortem examination we found the right upper lobe 
of the lungs was in many parts consolidated and of a gray color, 
and of a fine granular appearance, shading off in the natural red 
color in the parts pervious to air. There were in that lobe several 
small abscesses, and one as large as two walnuts. The right 
lower lobe, and to a less extent the left lower lobe, were consoli- 
dated and of a red color, leaving on the whole about six inches 
square of the whole pulmonary tissue permeable to air. The 
ventricular parietes of the heart were pale in patches, and the 
mitral valves white and thickened. The kidneys exhibited an 
atrophied appearance, the cortical structure being 'diminished in 
quantity and containing many small cysts. The liver had a 
thickened opaque capsule and a granular (nutmeg) appearance 
when cut into. 

Here are two examples of pneumonia in one patient. The first 
attack in the upper lobe she had rendered much more serious in 
its consequences than it otherwise would have been by starving 
herself. It had absolutely condensed the pulmonary tissue, and 
was running on to abscess on her admission. And she was re- 
duced to an extreme state of emaciation and weakness. So that 
a condition was present closely resembling tubercular consumption, 
and distinguishable from it only by the history. Yet the doubt- 
ful diagnosis gave me no anxiety, for it made not the slightest 
difference in the treatment of the patient, whose prescription- 
card made many of you set it down as an ordinary case of 
phthisis. 

I cannot forbear here leaving for a few minutes the considera- 
tion of the cases immediately before us, in order to make a few 
remarks which possibly at some future time may cheer your 
hearts under chilling anxiety. I know of nothing more fearful 
than the feeling that upon your knowledge or ignorance depends 
the life of a fellow-man. This feeling runs through, and ought 
to run through, your whole professional career ; for the good of 
your patients your consciences cannot be too tender. But it is 
necessarily experienced in very different degrees in different 
cases, and in the present age you will find your anxiety gener- 
18 



266 PNEUMONIA. 

ally turns upon diagnosis. The patients who make you dream 
and roll about in your bed of nights, and who spoil your appetite, 
are oftener those with whom you cannot find out what is the 
matter, than those with whom you do not know what to do. 
Now, it is often a great comfort to reflect, and I am sure it is 
true, that where pathological conditions closely resemble one 
another in the symptoms they produce, the treatment they 
require is probably exactly the same. I should be sorry to "lay 
a flattering unction to your souls," but this is simply justice to 
yourselves. How often is it impossible to ascertain, without 
questions which it is impossible to press, whether certain diseases 
are due to previous syphilitic infection or not ! Fortunately the 
same drugs are curative in both circumstances. How often do 
we reasonably fear to alarm a timid mind by inquiries into 
hereditary tendencies to lunacy or consumption ! The cases are 
exceptional where these inquiries are absolutely necessary. And 
in this instance it made no difference in the performance of my 
chief duty, that of prescribing for the patient, whether those 
were right who thought the consolidation was tubercular, or those 
who thought it pneumonic. 

The second attack of pneumonia happening under our eyes in 
the hospital, though hid from notice at first by its insidious 
manner of invasion, I cannot but attribute to the patient having 
got up and overworked her weak muscular powers. You may all 
be aware, from experience, how even in healthy persons unwonted 
exertion will cause temporary congestion of the respiratory tract. 
The stitch in the side and shortness of breath after running are 
well known. If we take violent exercise during catarrh, the 
mucus is often stained yellow some hours afterward. I have had 
haemoptysis on the morrow of a hard day's skating at Oxford. 
In an injured lung this tendency is still more marked and hurt- 
ful. Consumptive persons often spit blood the day after unusual 
exercise, although their hearts are quite sound. There was, 
then, nothing more likely than that this aged woman should get 
congestion from the same cause, and nothing more likely than 
that it should run on rapidly to consolidation in her weak state, 
and with her antecedent tendency to degeneration. It is a 



PNEUMONIA. 267 

warning to us to be more careful in watching over patients, and 
in avoiding everything which tends to exhaust the failing life. 

The degenerative tendencies made evident by the state of the 
kidneys, liver, and heart rendered the renewal of life very un- 
likely in this case. But that is nothing against doing our best. 
Patients as much degenerated as that often go about for years, 
and with extreme care may sometimes be brought round from 
apparently fatal illnesses. 

III. William W., aged thirty-seven, a post-boy, was admitted 
April 15, with extensive anasarca and some fluid in the pleura, 
arising from Bright's degeneration of the kidneys. He was 
treated with sesquichloricle of iron and hot-air baths. The 
dropsy diminished a little. On the 23d he got chilled by an 
open window, and on the 24th the dyspnoea increased very much, 
his previously sero-mucous expectoration acquired a rusty-brown 
color, and there was extensive fine crepitation in the lower lobes 
of both lungs. He was cupped between the shoulders, and a 
small quantity (six ounces) of blood taken. A jacket poultice 
was kept round his chest, and he took 5ss of ether, and TT|x of 
chloric ether every three hours, and four ounces of gin daily. 
The dyspnoea was somewhat alleviated by these means, and on 
the 27th the sputa became gradually purulent, instead of rusty. 
On the 29th it was still more purulent and copious. With the 
increased dyspnoea, induced by the attack of pneumonia, the 
anasarca of the arms, chest, and upper part of the body generally 
had very much increased. 

In this man's case the imminent danger arising from the 
pneumonia has indeed almost passed away, and the increased 
dropsy of the upper extremities, arising from the extra impedi- 
ment to the passage of blood through the lungs, is alleviated ; 
but I fear that his broken state of health forbids our hoping 
for his. final recovery. You may remark, however, that alcoholic 
stimulants, which certainly do not benefit albuminariacs in gen- 
eral, are here well borne and decidedly beneficial while the 
pneumonia is acute, and that they have sustained the patient 
while ready to perish. They have also not produced any tend- 
ency to coma (which is so much to be dreaded in these circum- 
stances), but have aided restorative action. 



268 PNEUMONIA. *'* 

This person had hardly a spark of life to spare, so as to allow 
of blood-letting to any extent, and it was only the imminent 
danger of death by congestion that induced me to employ the 
cupping. 

[The man died toward the end of May of gradually increas- 
ing dropsy in all the serous sacs, and anasarca. The pulmonary 
tissue at the back part of both lungs was scarcely crepitant. 
But it was not dark and congested, as is usual in cases of 
dropsy. It was mottled with yellow, as if it had been solidified 
by the pneumonia and were recovering. The kidneys were 
mottled and granular, not shrunken. His case is again alluded 
to a few pages on.] 

IV. George P., aged twenty-seven, a coachman, was warded 
on April 14. He had had a cough for four days. On the 13th 
had felt very ill, and in the evening of the same day an erup- 
tion of measles came out. His nose had been bleeding a little. 
His tongue was pretty natural ; the pulse 88 ; the respiration 
82 in a minute. There was fine crepitation without dullness, on 
percussion beneath the right scapula. He was ordered ten leeches 
beneath the right scapula that day, and ten the next, and a half- 
jacket poultice. He drew his breath much more easily after 
each application of the leeches. Dullness on percussion in the 
affected part, which was noted on the 16th, had disappeared on 
the 18th, and he took quinine till he left us on the 30th, the dull- 
ness gradually merging into moist crepitation of return. His cer- 
vical glands swelled as the eruption went off, and he had half a 
dozen leeches and hot fomentations to that part. 

Here, contrary to what I remarked in the last case, there 
was plenty of life and vigor. Very probably the man would 
have got over his pneumonia well under any circumstances, but 
the leeching certainly relieved his deep pain in the side (the 
stitch of congestion) and I think it made things more safe. For 
in measles the pneumonia is the variety conventionally named 
" catarrhal pneumonia," that is to say beginning with and arising 
from bronchial catarrh, and is very apt to go on spreading. 
It does not come on as it were with a gush, and involve at 



PNEUMONIA. 269 

once the pulmonary tissue it is going to involve, but creeps 
onward from lobule to lobule in a troublesome manner, unless 
checked. 

This is familiar enough to those who have much to do with 
measles, but I do not think I had an opportunity of remarking 
it to you before, because we so seldom have an example of that 
disease in the hospital wards. Occurring mostly in children, and 
being in them a malady of small moment unless complicated with 
pneumonia, it is rarely admitted into a general hospital. 

The swelling of the cervical glands is common in all zymotic 
diseases, and had nothing to do with the pneumonia. 

V. Samuel F., aged twenty-eight, a laborer, was seized on 
April 11 with a stitch in the right side and dyspnoea. I saw 
him on the 11th. There was fine crepitation, and comparative 
but far from absolute dullness on percussion in the lower half 
of the right lung. The expectoration contained some streaks of 
blood, and was a little yellowish. He had previously six leeches 
on his side. I ordered him sixteen more and a jacket poultice. 
On the 16th the expectoration was rusty, and his nose had been 
bleeding. His bowels were open for the first time since his 
illness. His pulse was 104, and soft. He had had delirium on 
the previous night. His tongue and hands were tremulous, and 
the tongue had a yellowish tinge like that produced by chewing 
tobacco, which however he had not been doing. He was ordered 
TTjx of laudanum every four hours and six ounces of port wine 
daily. 

By the 22d the crepitation of return was heard, though the 
expectoration continued to exhibit a yellowish tinge mixed with 
the pus of which its bulk consisted. He was ordered quinine, 
mutton-chop, and porter in place of the laudanum and teacup 
diet. 

On the 29th, cough and expectoration had ceased. 

Here the opiate treatment of pneumonia was adopted. I 
think it especially suited to cases where there is evidence of 
deficient power in the nervous system, where there is great 
prostration or tremor of the hands and tongue. Where also the 



270 PNEUMONIA. . % 

tongue has a smooth whitey-brown-paper colored coat. I give 
it also where there is diarrhoea, or even any tendency to diarrhoea, 
such as two fluid motions daily, in pneumonia ; for of all un- 
fortunate complications there is none so bad as looseness of 
bowels : those patients always do best who are constipated either 
naturally or artificially. 

When in consultation you are obliged to defer to the opinion 
of others, and give either mercury or antimony, especially the 
latter, in pneumonia, always make a proviso that a good dose of 
opium, shall be joined ; it prevents a great deal of the harm 
which normally results from the use of those drugs. 

It is remarked several times in the note book that no drowsi- 
ness was produced, although the opium was given to the extent 
of three grains daily. This is characteristic of the action of 
opium in acute inflammations, when it proves beneficial. If the 
'normal effect of the drug is fully manifested, I have not found 
that it has agreed so well. 

You will find it remarked on the 18th that the pulse was 
" reduplicating." This is rather an awkward attempt to trans- 
late Galen's term Skporog^ a character of arterial beat graphically 
compared by him to the stroke of a hammer brought down loosely 
on an anvil, which rebounds and so gives a second little stroke 
afterward. It seems he often found it in the malarious fevers 
of southern Europe, and observed that it indicated an approach- 
ing crisis. I should think that very probable, for it seems to 
me to arise from the renewal of the natural course and force 
of the circulation, when that return to health is associated 
with weakness -of the cerebro-spinal system — when the restored 
strength of the muscular tissue is not supported by a correspond- 
ing renovation of nervous function. It is an indication for the 
use of alcohol and opium, I think, although I have not observed 
it long enough to be sure. 

VI. Jane W., a young wife, the mother of one child, and six 
months pregnant with her second, was admitted April 12. She 
had been quite well in the morning of the previous day, till she 
was taken with sickness and cold shivers at 9 a.m. Between 
12 and 1 pain came on in the left side accompanied by dyspnoea. 



PNEUMONIA. 271 

She was treated with sixteen leeches, in two detachments, to the 
left side, jacket poultice and hydrochloric acid. On the 14th 
the case was identified as one of pneumonia by fine crepitation 
in the whole lower half of the left lung with very slight com- 
parative dullness on percussion, and she was put upon a grain of 
opium every three hours. The next day no sleepiness having 
■been produced by the opium, and the tongue being yellowish, 
white and pasty, she was put upon wine, but it seemed to pro- 
duce vomiting, and was left off next day. The crepitation was 
succeeded by absence of breath-sounds and increased dullness. 
On the 21st crepitation (of return) was heard, the appetite re- 
turned, and she was put on quinine instead of the opium. She 
was discharged cured on the 22d. The vomiting, due partly as 
it seemed to her pregnancy, did not recur. 

There is nothing particular to be remarked in this case re- 
specting the pneumonia and its opiate treatment, beyond the 
fact of the advanced pregnancy, which seems to have offered no 
impediment to its success. You may observe that wine in a 
young person unused to stimulants produced vomiting, which 
ceased on its omission after the trial of a few glasses. Vomiting 
in pregnancy is very often the consequence of persistence in 
taking alchoholic drinks. Alcohol is familiarly known to be an 
emetic when swallowed in excess, and in the sensitive state of 
the abdominal and thoracic nervous system which accompanies 
pregnancy, a very small quantity is in fact an excess, so far as 
this effect is concerned. Foolish women, feeling what they term 
" weak " from the extra weight of body they have to carry during 
pregnancy, and perhaps also glad of an excuse for indulgence, 
sometimes take an additional quantity of wine and beer at this 
time, and are punished by troublesome vomiting. This can often 
be checked at once by making them leave off the stimulant, and 
take only light digestible food in small frequent quantities. 

You may remark that she was put upon hydrochloric acid for 
a couple of clays. This was on her first admission, when the 
prostration, more than usual in single pneumonia, and caused 
probably by her journey to the hospital, made us suspect typh- 



272 PNEUMONIA. * 

fever. However, absence of delirium, of cutaneous eruption, 
and of any other signs of that fever, set the question at rest very 
soon, and fine crepitation in the pulmonary tissue pointed out 
the true disease. 



{Clinical, St. Marys, May 30, 1863.) 

I shall resume the subject of pneumonia with a few additional 
cases. 

VII. Elizabeth M., a girl of sixteen, was taken ill on May 
23, with drowsiness, nausea, vomiting, pain in her back and 
limbs, and in short the usual symptoms of typh-fever. On her 
admission, two days afterward, these were more decided, and 
the tongue was dry and brown in the center. But there were 
no fever spots, nor have any appeared since. She had some 
diarrhoea on admission, and there was pain on pressure of the 
left iliac fossa. On examination of the chest we found fine 
crepitation and slight comparative dullness in the left lower 
lobe, and this has since extended in a minor degree to the right 
lower lobe. On further examination we found also a valvular 
murmur with the first sound of the heart on the left side of the 
apex, very local and scarcely heard at the center of the heart, 
probably due to valvular disease from an attack of acute rheu^ 
matism two years ago. 

The only additions made to the usual treatment of typh-fever 
were six leeches beneath the shoulder-blade, a jacket poultice, 
and ten grains of compound kino powder three times during the 
first day. 

This case is distinguished by the very early occurrence of 
pneumonia in typh fever. It is not a mere congestion from the 
long gravitation of poisoned blood in the sluggish tissue, accord- 
ing to the commoner history of such accidents ; but it began the 
first day or the second day of the disorder. The probable ex- 
planation of this is the imperfection of the girl's heart, by which 
the circulation was more than ordinarily retarded. Observe 
how latent the pneumonic symptoms are : they came on quite 



PNEUMONIA. * 273 

unawares to the patient or her friends, and the lesion was made 
evident only by auscultation. It is usually so in typh-fever ; 
for the normal sensitiveness of the system is blunted by the 
poison, which by its effects might almost be called a narcotic 
poison, only that it does not produce true sleep. This is a warn- 
ing to be very industrious in not neglecting the use of your ears 
in all cases of typh-fever. 

The compound kino powder was ordered for the purpose of 
putting an immediate stop to the diarrhoea. The hydrochloric 
acid would have done that gradually in twelve or twenty-four 
hours, but a purged state of bowels is such a pernicious circum- 
stance in pneumonia, that I was in a greater hurry than usual to 
arrest it. 

VIII. Timothy MacC, a burly, hard-drinking brickmaker, 
about twenty-seven, we found in bed May 27. He was too ill to 
tell a consistent tale, but he stated that he had been quite well 
till the 22d, when, on getting up in the morning, he was seized 
with a trembling so severe that he could hardly dress himself, 
and was nearly two hours trying to do so. These "trembles" 
continued on admission; he could not hold his hand out straight, 
and said that when alone he saw flocks of sheep scampering past, 
and shadows of persons not really present. He had a hard bad 
cough, and his sputum was rusty and copious, with pus in it. On 
the right side of the chest, both in front and behind, there was 
a diminution of vocal resonance, dullness on percussion, segoph- 
ony, and coarse bronchial breathing. On the left side there was 
dullness on percussion a in the lower lobe behind, bronchophony and 
coarse rales. In the front of the same side there was puerile 
respiration. There was also stitch in the side and pleuritic fric- 
tion on both sides. The respirations were twenty-four, the pulse 
111 in a minute. 

He was ordered ten drops of laudanum in effervescing am- 
monia draughts three times a day, jacket poultice, teacup diet, 
and eight ounces of port wine daily. 

On the 28th the pulse was 120, the respirations forty-two. 
He was very delirious. A pint of bottled stout was ordered in 
addition to the wine. 



274 PNEUMONIA. . % 

He died early on the 29th, two days after admission. No post- 
mortem examination was allowed by the friends, who carried off 
the corpse directly. 

This is a case of that severe form of pneumonia which not 
uncommonly comes on as a consequence of delirium tremens in 
hard drinkers much exposed to the weather. The nervous symp- 
toms are, in proportion to their prominence, an unmistakable 
warning to avoid depressants and to keep up the patient's 
strength by all the means in your power. Bleeding such a man 
would probably kill him in raving mania, and I would not venture 
even to cup or leech him, useful as it would probably be to such 
a state of lung in a temperate strong person. Alcohol must be 
given without stint; but yet I fear that, however active and un- 
sparing your hand may be, you will still lose the greater number 
of your patients who have pneumonia come on in the course of 
delirium tremens. 

IX. George F., aged twenty-three, was attacked on the 3d of 
May with rigors, and about four hours afterward felt a severe 
lancinating pain in the right side, much increased by inspiration. 
He was sent up to bed as an urgent case in the evening, with 
great dyspnoea, a short sharp pulse, and dullness on percussion 
in the lower part of the right thorax. It seemed to be a case of 
pleurisy, and the house surgeon put him on mercurials and sa- 
lines, and applied leeches to the painful part. On the 6th, the 
sputa became tawny and speckled with blood. At that date, al- 
though the dullness on percussion was less marked than on 
admission, it was still present, but all over the infra-scapular 
region on the right side, and partially on the left, there was fine 
crepitation. He was then enveloped in a jacket poultice, and 
given seven minims of laudanum every three hours. On the 9th, 
the pneumonic sputa were still more strongly marked, and he was 
ordered, in addition to the opium, tincture of bark a,nd ammonia 
and port wine. Two or three days after we found the respira- 
tion quite absent in the lower lobes, though there was large 
bronchial breathing. But on the 16th crepitation began to 
return on the right side, and on the 18th some on the left side, 



PNEUMONIA. 275 

too — a joyful sound ! By the 20th it was well marked and clear 
on both sides, and I thought myself justified in ordering him 
ordinary diet and porter, though the sputa were still mixed, 
tawny, and purulent. 

Since then he has been steadily convalescing, with the assist- 
ance of a blister to the right side, where he felt some pain, and 
yesterday got up and partially dressed himself. 

There are two directions from which pneumonia attacks the 
lungs: it begins either from the inside, that is, the bronchial 
mucous membrane, in which event it constitutes catarrhal pneu- 
monia, or the "suffocative catarrh" of our forefathers; or from 
the outside, when it may be fairly named pleuro-pneumonia. The 
latter is exemplified by the present case. I should say that, as a 
rule, the chief danger of catarrhal pneumonia was at the first 
onset of the illness, when it sometimes ends very rapidly; while 
pleuro-pneumonia causes about an equal degree of danger through- 
out, till convalescence begins. And convalescence is generally 
in such cases very slow, the destroyed pleura not allowing the 
restored lung to expand freely so as to dilate the air-cells. The 
tissue, therefore, is apt to remain condensed. 

I dare say you wondered to see me order to a man, whose 
lungs were in 3uch a state as to cause dullness on percussion 
and crepitation, beef and porter like a laborer at work. But 
I reckoned that where there was vitality enough in the system 
to cause so quickly the returning sound of expansion, there was 
vitality enough to digest normal victuals. I do not say you can 
always succeed in getting solid meat digested thus early, but 
where you can, it shortens the convalescence very much. 

The mention of returning crepitation after pneumonia induces 
me to recall to your recollection a post-mortem examination 
which took place a fortnight ago on a patient about whom I lec- 
tured on May 2, William W., who died of anasarca from diseased 
heart and kidneys, in the course of recovery from pneumonia. 
I say "in the course of recovery," because the pulmonary tissue 
had again become partially crepitant, and the sanguineous ex- 
pectoration had ceased. After death we were able to see what 
pathological condition these signs indicated during life. The 



276 PNEUMONIA. * 

tissue of the back part of each lung was barely crepitant, but it 
floated in water and admitted some air. It was mottled, as if 
measle-spotted, with yellow and red : on pressing it hard a small 
quantity of thick fibro-purulent stuff could be squeezed out from 
the yellower portions, mit the others seemed quite empty. 

I have no doubt in my own mind, that the way in which con- 
solidated lung recovers, is by the exudated fibrin breaking down 
into pus and being expectorated, while the obstructed air- 
vesicles regain their elasticity and capacity for performing their 
functions. This is a strong argument for an ample supply of 
nutriment during the regenerative process. 

You may have remarked, both from the progress of this 
patient, who is slowly recovering, and from the post-mortal 
appearance of the lungs in the one who died from other causes 
during convalescence, that pneumonia is not a sudden attack, 
which strikes at once all the pulmonary tissue that is going to be 
affected. Its onward march is gradual; it creeps on from spot 
to spot, and from lung to lung. And its backward march is 
gradual too ; the parts first paralyzed in their functions recover 
first, and those last wounded recover last. This too they do, in 
spite of the latter being perhaps the least affected. 

It is from observations like these that the great advantage of 
our uost-mortem examinations is derived. The chief cause of 
death is often the least noteworthy fact about them. In nine 
cases out of ten it is some utterly irremediable organic lesion, 
the sight of which merely flatters your vanity by verifying your 
diagnosis. But the lesions which do not kill, and which are 
curable, are those you are concerned with, and to understand 
which makes you good practitioners. 



(Clinical, St. Mary's, July 11, 1863.) 

George F., about whom I lectured to you six weeks ago, has 
justified by the slowness of his convalescence the distinction I 
pointed out to you, between pneumonia commencing from the 
interior of the lung and from the outside. The lower right lobe 
still remains dull on percussion, and air is very sparingly ad- 



PNEUMONIA. 277 

mitted into it. Some parts of the pulmonary tissue have also 
broken down into a small abscess in the front part of the lower 
lobe. He has fortunately no hectic, and is getting strong and 
stout slowly upon iodide of iron and cod-liver oil. The ribs will 
probably fall in on that side just as they do after empyema, but 
we shall not be able to keep him in the hospital long enough for 
you to see this result. 

Two other cases of pneumonia were taken iu yesterday week. 

X. Mary P., a child just at the age of puberty, was admitted 
July 2. She had had cough and cold for a short time, but did 
not give up her work as a domestic servant till the morning of 
her admission, when she was taken very ill, with shortness of 
breath. On admission the breathing was very labored, and she 
raised the alae nasi in inspiration. The respirations were 44 in 
the minute ; the pulse 144. There was bronchial breathing and 
whistling rales all over the chest. The whole of the right lobe 
was dull on percussion. No stitch in the side, or pain on 
pressure. She was cupped to §iv between the shoulders, eight 
leeches were applied beneath the shoulder-blades, and the chest 
was enveloped in a jacket poultice. I also ordered her TT[x of 
laudanum every three hours and teacup diet. 

On the 4th, when I came round, she was asleep, and the respi- 
ration was evidently so much relieved that I did not care to rouse 
her. She had expectorated some blo6d-stained mucus. 

On the 5th the pulse was 130; the respirations 36. 

On the 8th the pulse was 120 ; the respirations 26. The dull- 
ness on percussion extended half way up the right lung, and 
coarse crepitation had succeeded to the whistling rales. The 
tongue was brown ; but that did not seem caused by any aggra- 
vation of the symptoms. On inquiry, I found she had been 
sleeping that night and morning much more than usual, and sus- 
pected that the brown coat of epithelium was caused by the 
opium. I left off all drugs, and trusted to the poultice only. 

On the 9th her tongue was clean. 

To-day (the 11th) the respirations are natural, and the air 
enters freely to the base of the lung, which is resonant on per- 
cussion. Only on a full inspiration can you hear a little crack- 



278 PNEUMONIA/* 

ling in the pulmonary tissue. The sputa are purulent, with a 
slight orange tinge in some specimens. She says her bowels 
have not been open the last six days. She makes so much of 
this observation, that I have given her a dose of castor oil, to 
quiet her mind. 

Remark in this girl how severe the symptoms were at first, 
how dangerous indeed to life, yet how soon the alarming part of 
them passed away. This would not have been the case if she 
had. had pleuritic pneumonia, instead of catarrhal or bronchitic 
pneumonia. 

The opium agreed with her very well; but ten drops every 
three hours is a large dose for a child, and therefore, when it 
did not seem to be demanded by the symptoms, I was glad to 
leave it off. You will usually find that the time for doing so is 
marked by tolerance of the drug ceasing, and increased drow- 
siness coming on. 

Remark the constipation, and how well it agrees with pneu- 
monic patients. 

XI. George L., a muscular laborer, aged thirty-two, came 
under my care July 3. He confessed to being a hard drinker, 
and to having had several attacks of delirium tremens. After 
ailing for a few days to such an extent only as allowed him to go 
on with his work, he was taken on June 30 with rigors and 
dyspnoea, so as to completely prostrate him. When I saw him 
the respirations were 60; the pulse small, 140; his tongue 
thickly coated. The skin was hot and dry, and there was an 
eruption of herpes on the lips. There was dullness on percus- 
sion, with bronchial breathing, in the whole of the right lower 
lobe, and dullness less decided in the lower part of the left 
lower lobe, with fine crepitation at the upper level of the dull- 
ness. He was cupped to Sviij beneath the shoulder-blades, put 
in a jacket poultice, and ordered twenty minims of laudanum 
every four hours, and teacup diet every two hours. 

On the 4th the pulse was 130, larger and fuller; the respira- 
tions 44. 

On the 5th the pulse was 120 ; the respirations 40. I found 
him raised in bed and reading a newspaper. 



PNEUMONIA. 279 

On the 6th the pulse was 132 ; the respirations 36. He had 
been noisy and delirious the night before. Four ounces of port 
were ordered to be added to the treatment, to be taken at night. 

On the 7th tawny expectoration commenced. 

On the 8th pulse 108; respirations 36. 

To-day (the 11th) his pulse is 100; the respirations 26; the 
air enters freely into the right lower lobe, with only a certain 
coarseness .on full inspiration. That part is also resonant on 
percussion. In the left lower lobe a slight comparative dullness 
remains, and there are the crackles of returning breath-sounds. 

The lung tissue you see has returned to its allegiance in the 
order in which it ceased to work. First the right lower lobe, 
which was the most condensed on admission, and was the first 
affected ; then the left lower lobe, which was the last to suffer, 
and is, therefore, the last to get well. Pneumonia does not 
strike like a thunder-bolt the whole that is going to be injured, 
but creeps on from one spot to another, and creeps away in the 
same order. 

The remark which I made in the last case as to the form of 
pneumonia, and the alarming earliness of its severe symptoms, 
applies equally to this man. Though his breathing was so short, 
and his pulse so quick on the 4th, yet on the 5th he had strength 
enough to be reading his Sunday newspaper. But the exertion 
was as bad for his body as the politics doubtless were for his 
mind, and in the evening he got delirious, and was inconveniently 
violent during the night. I had hoped to spare our wine but was 
forced by this delirium to order him a couple of glasses of port 
to be taken every evening. 

You may learn by this instance how important quiet is in 
pneumonia both for mind and body. Nearly all our dangerous 
and fatal cases are made dangerous and fatal by neglect of this ; 
and though this patient is not seriously injured by his imprudent 
obstinacy, yet I have no doubt his convalescence will be the 
longer for it, and we have had to give him stimulants which 
might possibly have been spared. If the stimulants had not 
been given, he would very likely have had delirium tremens ; 



280 PNEUMONIA. . „ 

the lungs would have become more congested, and he might 
have died like a man I lectured about on a late occasion. (See 
Case VIII.) 

When I say this, however, I ought to guard my words. For 
in reality he would not have been in anything like the danger 
of that poor fellow. Truly enough the two diseases are a most 
perilous combination ; but it makes a great deal of difference 
whether the pneumonia is a consequence of an antecedent 
delirium tremens, or whether the delirium tremens is a con- 
sequence of the pneumonia coming on a predisposed subject. 
In the former case a fatal result almost invariably happens, but 
not so in the latter. So that though he might have died, yet he 
would not have been so certain to die as our former patient. 

XII. A little boy, four years old, was conveyed here on the 
3d instant, just at his last gasp, and died about a quarter of an 
hour after I had seen him, while the sister was putting him into 
a poultice, and giving him some wine and beef-tea. 

It was entered in the " urgent admission book" as a case of 
pneumonia ; and so there was pneumonia, but it had nothing to 
do with his death, which in reality arose from the impaction 
of a calculus in the right ureter and inflammation of the kidney 
following thereon. The pneumonia was a consequence, not 
a cause, being of the sort fairly designated " pneumonia mom- 
entum" It was the consolidation of scarce a half of the right 
lower lobe by this congestion of gravitation which caused the 
patient to be entered as I have said, and placed in the medical 
wards. Had that been the only anatomical change, this child 
might easily have recovered ; and I mention the case only to 
guard you against crediting the death purely to pneumonia. 

The dozen cases of pneumonia which I have made the subject 
of a considerable portion of three clinical lectures since Easter,* 
may be held to be a fair representation of an average four 
months' hospital experience of the disease. There have been 
specimens of its most ordinary forms very much in the pro- 

* Viz., o» May 2, May 30, and July 11. They are here massed together into 
one lecture. 



PNEUMONIA. 281 

portions in which they will occur to yon in practice. They have 
included 

2 cases of pleuro -pneumonia, one fatal, one not (VIII, IX). 
1 case of pneumonia in measles (IV). 
1 case of pneumonia in typh-fever (VII). 
1 case of pneumonia in Bright's disease (III). 
1 fatal case of pneumonia relapsing on a previously consoli- 
dated and broken-down lung (II). 
5 cases occurring in previously healthy persons (I, V, VI, 

X, XI). 
1 case occurring as a complication of the death agony from 

another disease (XII). 
In the fatal cases the death was caused in one by the pneu- 
monia coming on a previously consolidated lung (II), in the 
other on a severe attack of delirium tremens (VIII). In the 
third the pneumonia was caused by the death (XII). 

And as to treatment I have taken current opportunities of 
impressing upon you the following rules : 

I. Take blood locally, cautiously, in the early stage only, 
and with a distinct reference to the power of each 
patient. 
II. Keep the chest from first to last enveloped in a jacket 
poultice, and allow of as little movement as possible. 

III. Administer food frequently, largely, and in a liquid 

form. 

IV. Where the nervous system is deeply smitten, as indicated 

by tremulous muscles, mental excitement, delirium, 
tawny tongue at an early stage, great depression, &c, 
give opium ; and in some cases give alcohol, but not in 
small repeated doses. 
V. Where there is diarrhoea, stop it immediately with opium 
or kino. 
VI. Consider antimony, mercury, and purgatives as poisons 

in pneumonia. 
I have heard the plans of treatment which I recommend you 
to adopt described as "trusting to nature;" and sometimes a 
deprecatory "merely" is added — "merely trusting to nature." 
19 * 



282 PNEUMONIA. 

In one sense this is true, for all methods of cure, at least all 
successful methods of cure, must depend on the regaining of 
natural vital forces ; and the agencies brought into action by our 
interference must be the natural vital forces of the body acted 
upon. The heat and moisture, for example, which we employ in 
pneumonia, are an imitation of and compensation for the de- 
ficient steadiness of the vital warmth ; the current of blood which 
we cause to flow with our cupping-glasses is a replacement of 
the natural current ; we give opium to bring the condition of the 
nervous system into harmony with the functions arrested by the 
disease. There is no successful method of cure but what is suc- 
cessful by virtue of thus restoring vitality. But in the sense 
intended by those who slightingly use them, the words are 
synonymous with doing nothing, or leaving the patient to him- 
self, with la medeeine expectante, with the contemplatio mortis of 
the satirist, with a hardened skepticism. It is a saying like those 
clever sneers of Job's adversary, which, under the guise of a 
truism, hide a lie. 

Doing nothing or leaving the patient to himself, would indeed 
be dishonest ; but do we do so ? Is it doing nothing to keep up 
constant relays of poultices night and day for a week or ten 
days? Is the enforcement of continuous nutrition no labor? 
Is there no anxiety and thought expended in hourly watching 
the need of variation in our doses of opium and wine for serious 
cases ? Is the moistening and warming the air to an even tem- 
perature not enough to occupy our time ? Is it so much easier 
to support the waning life than to weaken it, that the former 
should be condemned as idleness, the latter praised as activity ? 
If the pneumonic patient were left to himself, would he — could 
he — adopt any of the means suitable for his recovery ? Would 
he not very likely be taking colocynth, senna, calomel, anti- 
mony, ipecacuanha, salines, senega, squill, hydrocyanic acid, 
colchicum, be rubbing in mercury, applying mustard poultices 
and blisters, be bled coup sur coup, or have brandy every half 
hour ? Is it nothing to stand sentry against the fatal seductions 
of poly-pharmacy ? 



LECTURE XXII. 

EMPHYSEMA OF THE LUNGS. 

Illustration of the morbid anatomy of emphysema — Fatty degene- 
ration of the pulmonary membrane — Degeneration sometimes 
fibroid — Cause of the pr oneness of children's lungs to become 
emphysematous — Question whether inspiration or expiration 
most tends to produce emphysema — Action of the lungs in 
breathing illustrated by an example of a man without a 
sternum — Expiration more powerful than inspiration — Ap- 
plication of the morbid anatomy of emphysema to clinical 
questions — Case of emphysema in an albuminuriac — Case 
of emphysema depressing the heart — Treatment and its ob- 
jects — Iron — Tobacco — Lobelia — Stramonium — Mercury — 
Alcohol — Expectorants — Two cases of emphysema in young 
women exposed to adverse circumstances — Treatment by 
iron — Trial of expectorants. 

{Clinical, St. Marys, March 13, 1863.) 

The following case, of which you now see the post-mortem 
examination, is a fair illustration of the morbid anatomy of pul- 
monary emphysema. 

Of the diseases which the deceased had suffered from de- 
pendent on this condition the history was given by him as fol- 
lows : 

George W., aged forty-two, a temperate laborer, much exposed 
by his work to cold and wet, had always "a good wind" till 
three years ago. Since that time he has been what he terms 
"asthmatic," that is to say, he has been habitually short of 
breath and liable to contract catarrh accompanied by dyspnoea 



284 EMPHYSEMA OF THE LUNGS. 

on moderate exposure. He was still always able to do an average 
day's work till last Christmas, since which time he has been too 
short of breath. He cannot assign any cause for his illness except 
exposure to cold. 

When you first examined him, March 2, he was breathing 
spasmodically and with extreme difficulty ; his lips and face were 
dark purple, but without any of the bloated appearance you so 
commonly see in cases of dyspnoea from enlarged heart. On 
examining the chest we found the cardiac region, as well as the 
whole lower part of the thorax, preternaturally resonant, and 
the ribs Were bowed and raised, so as to make the bony frame- 
work of the upper half of the trunk more globular than natural, 
and to throw backward the lower angle of the scapula. The 
. intercostal spaces were not protuberant. The number of respira- 
tions was thirty-four in a minute, the pulse 104. In the cardiac 
region, and in several other of the lower parts of the chest, I 
drew your attention to a peculiar crumpling sound in inspiration, 
not unlike that produced by squeezing up fine paper in the 
hand. 

He experienced a certain degree of relief from the rest in bed, 
and a draught three times a day containing lobelia and chloric 
ether ; so that on the 4th his respirations were reduced to 
twenty-eight in a minute. 

But he soon fell back again, and sank exhausted and breath- 
less on the 11th, and we have now to make the post-mortem 
examination. 

On opening the chest the heart is seen completely overlapped 
and hidden by a layer of lung about two inches thick, consisting 
of lobular masses of pulmonary tissue, pale in tint, dilated into 
vesicles, and looking more like flesh-colored soapsuds than any- 
thing else. These masses of vesicles are firm and elastic from 
retained air ; but when that is let off by a puncture, they sink 
down into a flabby non-crepitant substance. The same appear- 
ance is seen in the greater part of the lower left lobe, and at the 
apex of the upper lobe ; and the lower right lobe is partly in a 
similar condition. The flesh of the heart is pale, and its cavities 
are large. The wall of the left ventricle is thinner perhaps than 



EMPHYSEMA OF THE LUNGS. 285 

natural, but the whole organ is not so much dilated as to render 
the valves inefficient ; and they are healthy in appearance. The 
kidneys and other viscera are quite normal. 

On the whole you are perhaps rather surprised at the small 
extent of obvious organic change, considering the violence and 
fatality of the symptoms. But now examine again the portions 
of lung not affected with these bullae of emphysema. They are 
doughy, flabby, and non-elastic. They keep the mark of a finger 
pressed upon them. They are very slightly crepitant when 
squeezed. You may reasonably feel doubtful whether such pul- 
monary tissue can perform the functions which require elasticity 
and firmness. 

Now let us make a section, and cut out with a pair of curved 
scissors a few snips as fine as we can, tease them out with a 
needle, and place them under the microscope with a lens of one- 
quarter inch focus. You thus get a sight of the pulmonary 
membrane. You know it ought to be a continuous skin-like 
membrane, transparent, and distinguished principally by bundles 
of fibers gently curled and interlaced. In a healthy lung it does 
not exhibit any cells or corpuscles. But here you see scattered 
about it numerous fine dark specks, and somewheres there are 
round bright globules with a dark outline, and somewheres the 
globules and specks are collected together into masses, denser 

toward the center — so ^!, 6 t ,'/j • -" — just like the masses of 

fatty degeneration which you have in the muscular structure of 
atrophied hearts. This is an example in fact of the same morbid 
state in another tissue, the fatty degeneration of pulmonary 
instead of cardiac tissue. 

You will easily understand how emphysematous bullae arise. 
Melt one side of an India-rubber ball in a candle and squeeze it; 
you see it bulge out into a bubble just in the same way, and just 
from the same cause, loss of elasticity. What the melting is to 
the India-rubber ball that to the pulmonary branch of vesicles is 
the wasting of its elastic web into fat. When any dilated force 
is exerted upon the walls of the vesicles they give way and do 
not contract again. 



286 EMPHYSEMA OF THE LUNGS. 

It is not always fatty degeneration which is found in emphy- 
sematous lungs ; sometimes it is fibroid degeneration, and Dr. 
Jenner has in his experience found this latter the most common.* 
Either sort of partial interstitial death involves a loss of the func- 
tions of elasticity and contractility in the tissue — fatty degenera- 
tion probably the most loss, and therefore it is that you find it in the 
most rapidly fatal and most marked cases, such as the one under 
our eyes. The same softness and proneness to give way may also 
be supposed to exist in the lungs of children ; for the younger 
the tissue the softer it is ; and thus children's lungs are very 
prone to become emphysematous without there being any inter- 
stitial change to be detected in the pulmonary tissue. 

The anatomical or predisposing cause of the disease we are 
considering may^then be held to be a too great softness of tissue, 
from the lung either not having yet acquired its full power of 
resistance, or from having lost it by morbid change. 

And now let us look for the external or determining cause, 
quite as important an element in the production of disease. It 
is the act of breathing of course, and the act of breathing forcibly, 
that breaks down the over-soft tissue. But is it inspiration or 
expiration that is most to blame, or both equally ? The question 
rests on the point of which causes most pressure of air on the 
pulmonary membrane of the air-cells. And because inspiration 
fills these air-cells, it has appeared to some to cause most pressure 
on their walls. Doubtless in inflating a bladder you increase the 
atmospheric pressure on the inside, and I suppose it must be this 
analogy which has led physiologists astray. But the cases are 
quite different ; the lungs are not inflated by blowing air into 
them, but by the expansion of their walls drawing air into them, 
in fact by the atmospheric pressure on the interior being forcibly 
lessened through the action of the diaphragm and other respira- 
tory muscles. A fairer analogy would be a pair of bellows, the 
leathern sides of which are certainly not bulged outward by the 
filling of the instrument. And if that leather was softened it 
would swell and stretch during the blowing of the fire, not during 
the drawing in of the air. 

* " Medico-Chirurgical Transactions/' vol. xl, p. 26. 



EMPHYSEMA OF THE LUNGS. 287 

Not inspiration, but expiration, must be the most efficient 
determining cause of the dilatation of the air-vesicles in emphy- 
sema. The difficulty which people feel in understanding this 
arises from their thinking of the thoracic walls as a contracting 
ball or box, of equal contracting force throughout, and which 
therefore in its contraction during expiration would equally 
diminish the area of all the pulmonary vesicles at once. And 
diminishing the area, say they, is certainly inconsistent with 
dilatation. But this idea of the chest is an erroneous one. The 
thoracic walls, from their irregular shape and from their varying 
solidity in various parts, press with a very unequal degree of 
force on different parts of the lungs. The apices of the upper 
lobes for example, from the deficiency of the bony framework 
above them, and the edges of the lower lobes from being in an 
angle, escape the compression of the ribs and diaphragm to a 
great extent. When then the air by the action of the respiratory 
muscles is squeezed out of the more readily compressed parts, it 
is driven into or at least is driven toward these less compressed 
parts. 

Two or three years ago some of you were shown in this 
theater the action of expiration upon the less compressed parts 
of the lungs by a M. Groux, a poor gentleman with a congenital 
deficiency of the sternum and a consequent fissure in the thoracic 
walls, which fissure was covered only by skin and cellular tissue. 
Of course the portions of lung behind this fissure were less com- 
pressed than any part of the pulmonary substance; and during 
expiration you saw them bulge out, just like the leathern sides of 
a bellows during a corresponding movement. Those who witnessed 
the curious sight admired the toughness of pulmonary tissue which 
could resist injury from such an abnormal state of things. And 
they could not fail to understand that if M. Groux's lungs had 
been wanting in elasticity, they would never have been able to 
resist the dilating power exerted by expiration on this undefended 
part of the tissue. The same condition which M. Groux's de- 
ficiency of sternum exhibited in an exaggerated way, the normal 
partial deficiency of bony framework presents in a less degree 
to the apices of the lungs, and their peculiar angular position to 



288 EMPHYSEMA OF THE LUNGS. 

the bases. It is in these parts that expiration causes the atmos- 
pheric pressure to be greatest, and it is in these parts that 
emphysema most commonly appears, as exemplified in the instance 
before us. It is at the apices and anterior edges of the lungs 
indubitably that we most often find this morbid state when the 
degeneration is generally diffused. 

When emphysema appears elsewhere in the lungs, the apices 
and edges being free from it, it is due to the degeneration being 
local, and to those peculiarly liable parts at apices and bases 
being shielded from injury by their healthy elasticity. 

Another reason for thinking that expiration rather than in- 
spiration is the main cause of the final injury to the vesicles in 
emphysema, is that it is much the most powerful of the two 
muscular efforts. If a man can draw in the air through his nos- 
trils* with sufficient force to raise a column of mercury (say) two 
inches, he can by expelling it steadily raise the level 2J inches : 
if he is strong enough to lift the fluid by inspiration 2 J inches, 
his expiratory power will mark 3J. Thus, even though it is pos- 
sible that both inspiration and expiration may tend to rupture 
or dilate the pulmonary membrane, inasmuch as all motion must 
endanger an abnormally friable tissue, yet expiration tends to do 
so much the most. That is the real practical point, as I will 
show you presently, when I come to apply our knowledge to its 
true end, the relief of distress. 

This fatal case then has shown you the true nature of the 
anatomical injury you have to deal with in emphysema of the 
lung. It is an interstitial partial death, or degeneration of the 
pulmonary membrane. This membrane, which forms the frame- 
work of the vesicles, thus loses its elasticity and is determined 
to dilatation by the action of forced expiration. 

It may be asked whether the degeneration is not rather the 
result instead of the cause of the dilatation. It may be suggested 
that bronchitis and violent cough originate the rupture of the 

* The nostrils must be used in the experiment, because the action of the 
tongue and cheeks in suction and puffing- introduce a fallacy, bringing into use 
muscles which are not muscles of respiration. See Dr. Hutchinson's paper in 
" Medico-Chirurgical Transactions," vol. xxix, p. 199. 



EMPHYSEMA OF THE LUNGS. 289 

vesicles, and that the ruptured vesicles, being unused, fall, like 
all unused tissues, into fatty decay. I will not deny the pos- 
sibility of such a sequence of events in some instances, because 
in point of fact we do find emphysema of unaltered pulmonary 
tissue in children. But it was not so in the case before us, be- 
cause the patient had not been subject to bronchial catarrh, had 
no mucous secretion before he got short of breath, and indeed 
had very little even up to the fatal termination. And the case 
before us is a well-marked type of uncomplicated emphysema in 
the adult. 

Do not rest satisfied with having learnt the pathology of a 
disease without applying the pathology to its treatment. If it 
were not capable of such an application I should not make it a 
subject for clinical lecturing. The pathology of emphysema 
shows us a gradually increasing loss of vitality in the pulmonary 
membrane. We must so treat the patient as to increase the 
vitality. A constant supply of nutritious food and long courses 
of iron give the best chances of doing this. I should have 
adopted it for our poor patient had he lived long enough. 

The pathology may teach something more. Expiration is 
the dangerous and injurious part of breathing, and especially 
forced and arrested expiration. Let your patient carefully 
avoid all such employments as strain the respiratory muscles — 
all such labors as make a man hold in his breath and then puff 
it out with a jerk — such as lifting and carrying heavy weights, 
digging, pitching, rowing, &c. I do not think you need trouble 
yourselves about wind instruments or singing ; persons with em- 
physematous lungs are not likely to be addicted to them, and as 
a matter of fact those who use the chest freely, such as public 
singers, do not get emphysema from the exercise of their pro- 
fession. Of this latter fact I am certain — it is not the due use ? 
not the " straining" of the pulmonary membrane which causes it 
to degenerate, but rather the want of use. In this respect it 
resembles all other living animal tissues. 



290 EMPHYSEMA OF THE LUNGS. 

(Clinical, St. Mary s, March 27, 1863.) 

I will take the opportunity of having admitted, a week ago, 
two cases of pulmonary emphysema, to recur to our subject of 
a recent lecture. 

" John D. is a poor street-sweeper now, and nearly seventy 
years old, but has been a gentleman's servant, and has had 'his 
beer regular,' and taken it freely. This confession is corrobo- 
rated by the shaking of his hands when he puts them up. He 
says he has been * queer and wheezy' and subject to frequent 
coughs for six years, and five years ago was under my care for 
asthenic gout. The cough is of a violent spasmodic character, 
and does not bring up much mucus. His chest is resonant and 
rounded, and moves very little on inspiration. The cardiac 
dullness commences at a low level at the base of the heart, and 
the pulsations of the organ are felt in the epigastrium. His 
corpulence prevents us from getting the auscultatory signs of 
emphysema so clearly marked as one would wish. There is not 
now, nor does there ever appear to have been,, any anasarca. 

" The urine is albuminous, of the specific gravity 1*012." 

In this case I think there is a generally distributed deficiency 
of elasticity in the pulmonary tissue, which has arisen from the 
same diathesis as the morbid state of his kidneys (shown by the 
albumen in the urine) and perhaps of other organs as well. But 
his general weak health, graphically described by him as 
" queer," has prevented his working hard, though I-dare say he has 
lived hard and drank hard : and in consequence the determining 
cause which I explained to you fully, in my lecture a fortnight 
ago, of forced and impeded expiration, has not been present. Thus 
local spots of very marked emphysema are not found. The de- 
fective vitality of the renal tissue, which makes him an albumin- 
uriac, is doubtless of the same nature as that in the lungs : and 
it causes a tendency in the blood to throw out its serum and thus 
to saturate the lungs with fluid, which assists also in concealing 
from our ears the signs of the emphysema present. 

The prognosis is certainly favorable as far as his chest is con- 
cerned, but I fear we cannot make a young man of him. 



EMPHYSEMA OF THE LUNGS. 291 

The other case is the following : 

" George EL, aged fifty-three, a plasterer, first became asth- 
matic two years and a half ago. After suffering a few weeks 
and expectorating a little mucus streaked with blood, he was 
admitted into the hospital under Dr. Sibson, and remained six 
weeks, having during that period had a carbuncle on his neck 
and an abscess in the left axilla. He went out relieved, and 
has been able to work ever since, in spite of his asthma, till a 
month before Christmas last, when he again was obliged to give 
up. On his coming under my charge, March 20, he presented 
the usual marked signs of extensive emphysema of the lungs. 
His chest is rounded, and the lower angles of the scapula are 
thrown upward and outward. The left side of the thorax is 
larger and more rounded than the right. There is very marked 
resonance all over it, including the cardiac region, and the heart 
is pressed downward, pulsating regularly in the epigastrium ; 
the valve sounds are healthy. The breathing is abdominal ; the 
respirations are twenty-eight in a minute. The face is livid, 
and the lips blue, but without any of that bloated appearance so 
common in asthma from diseased heart. There is a good deal 
of frothy expectoration, but no blood streaks in it. The urine 
is healthy." 

While examining this and some other emphysematous chests, 
I have been asked by pupils how it is that there is no bulging of 
the intercostal spaces, and I have been given to understand that 
bulging of the intercostal spaces is taught as a sign of emphy- 
sema at some schools. This is an error — the intercostal spaces 
do not "bulge," like as when the pleurae are full of fluid, a fact 
which you may ascertain for yourselves now. But of course 
from the chest being always in a state of fullness, the ribs are 
widely separated from one another. This, however, is a very 
different thing from intercostal bulging, as you may see in both 
the dead and living body. 

I have ascertained, by a reference to Dr. Sibson's case-book, 
that the signs and symptoms exhibited by this patient were 
much the same on his former admission as they are now. He 
is not essentially worse, and indeed his trade is not one which, 



292 EMPHYSEMA OF THE LtJNGS. 

with ordinary care and prudence, would be an injurious one. 
The prognosis therefore may be favorable. 

I will view as one the treatment of these two persons, inas- 
much as I have ordered them both the same medicine, viz. : 

^ Tinct. ferri sesquichloridi TTLxx, 
Tinct. lobelise setherese TTLxv, 
Mist camphor ee §j, 

ter die. 

The object of the iron is to try and restore its full vital powers 
to the creative arterial blood, so that it may renew the pulmonary 
membrane, that it may form healthy elastic tissue, instead of the 
imperfectly elastic degenerated tissue. That places where the 
walls of the air-vesicles are broken away, and where bullse exist 
instead of vesicles, should be filled up again with a new growth 
is, I fear, out of the question ; but that where the form of the 
lung substance remains perfect, where to the naked eye it is 
intact, and only under the microscope exhibits its incipient 
death, there I believe we need not despair of our restorative 
agent having a fair chance of success. The best restorative 
medicine is the healthy blood of the patient's own body, and to 
make that blood healthy is the most rational aim we can have. 

To the iron I shall at a future day add, in the case of George 
PL, cod-liver oil, as a means of affording a molecular base to the 
growth of new tissue. He is thin, as you see, and it will be 
readily absorbed by the intestines, and probably agree well with 
him. I feel more doubtful about oil in the case of John D., as 
he is so flabbily corpulent ; but I shall try cautiously how he 
bears it. 

You may have remarked that I refused the very urgent re- 
quest of John D. for beer, w T hich he said habit had made a 
necessary for him. , I hope, if possible, to break. him of the 
habit, for nothing is so injurious to degenerative tendencies as 
alcohol, and no form of alcoholic liquid so bad as beer. 

No — I must make one exception to the bad pre-eminence of 
alcohol, that is, mercury. Avoid mercury in these cases as you 
would a poison. Avoid also purgatives. 



EMPHYSEMA OF THE LUNGS. 293 

The lobelia is ordered as a substitute for a more powerful 
medicinal agent, tobacco. Nothing calms the distressing asthma 
so well as a few whiffs of strong Virginia. But to allow smoking 
in the hospital would lead to breaches of discipline ; so I order 
that which is apparently the next best thing. Like tobacco, 
lobelia is a very variable article ; there seems to be as much 
difference between one specimen and another, as between the 
mildest cigarette and the strongest shag. This accounts for 
what we read of enormous doses being sometimes perfectly inert, 
and of much less quantities having acted as a poison. A further 
safety to those who have taken large doses lies in the fact of its 
being, like tobacco, an emetic, and so freeing the stomach of its 
presence in excess. I should advise you to use the strongest 
sort, paying the best price at the best shop, so that you may 
give 'it in moderate and graduated doses. Lobelia does not 
disagree with the digestion like opium, and you need not on that 
score abstain from its use. 

Another agent of the same character as tobacco is stramo- 
nium. It also is best administered in a pipe, but here again 
the hospital discipline interferes, and I am obliged to give it 
him in pills made with the extract, which you may see are not 
so efficient in this instance as the lobelia, though in the form of 
smoke it is often more useful. 

Perhaps some of you may doubt whether it is quite wise to 
diminish by calmatives the action of the respiratory function, 
and may think the asthma an effort of nature, ordained to ac- 
company emphysema for a beneficial purpose. This is a case in 
point very subversive of the theory of disease being an "effort 
of nature." The forced breathing, nay, even the natural breath- 
ing, tends to dilate the vesicles, and if it were designed to benefit 
the patient, we should have to conclude that the design was erro- 
neous — a conclusion repugnant to instinctive reverence. 

When there is an unhealthy condition of the mucous mem- 
brane of the trachea and large bronchi, evinced by copious ex- 
pectoration, you will find benefit from cantharides or turpentine, 
either administered by the mouth, or applied to the surface of 
the chest in the form of blisters and rubefacient embrocations. 



294 EMPHYSEMA OF THE LMGS. 

These drugs often act very powerfully as restoratives of healthy 
action to diseased mucous membranes. They indirectly in this 
way benefit the emphysematous lung, by preventing the neces- 
sity for so much coughing; but they are not directly useful to 
the tissue mainly at fault. 

I do not approve of the use of squill or ipecacuanha, and still 
less of antimony. Even if they appear to relieve for the mo- 
ment, which is by no means generally the case, yet they lower 
the appetite and the powers of digestion, and thus stand in the 
way of active restorative treatment in emphysema. 

(Clinical, St. Marys, October 31, 1863.) 

There have been under your eyes during the month two cases 
very graphically illustrative of the pathology of emphysema. 

On October 7, there was received from the Servant's Home 
(where she had been living, while attending as an out-patient) 
Annie C, aged seventeen, a fat but stunted maid of all work. 
She was in the hospital during the summer of last year, and I 
find that her illness then was a typh-fever, slight in itself, but 
which had come on during a wet and cold foot-journey from 
Norfolk, and which had, under the adverse circumstances of its 
supervention, caused pneumonia of the lower lobes. She re- 
covered perfectly to all appearance both the use of her lungs 
and her flesh at that time. But yet she says she has never 
quite ceased to suffer from shortness of breath. This shortness 
of breath has been gradually growing upon her, and prevents 
her keeping any place as a domestic servant. On admission she 
was very blue in the lips and face, and was suffering great dys- 
pnoea; the respirations being forty in the minute. She said she 
had not been able to lie down in bed for two months. There 
were loud snoring and cooing rales throughout the lungs, inter- 
spersed with occasional cracklings in various parts, a roundness 
of the thoracic walls, abdominal and heaving respiration, and 
resonance on percussion more extensive in every direction than 
it ought to be. The heart, however, is not entirely overlapped 
by the lung, so that this evidence of local emphysema in the left 
rung is not complete. Its sounds are healthy. 



EMPHYSEMA OF THE LUNGS. 295 

Emphysema is not usual in girls of seventeen, and we are able 
therefore the more distinctly to refer this case to the peculiar 
adverse circumstances in which she had been placed. Con- 
gestive inflammation of the pulmonary substance had been in- 
duced by exposure in a person previously disposed to it by the 
typhous state. The congestion had been relieved by treatment, 
but there was left behind the weakened life of the tissue unable 
completely to recover itself. This has resulted in gradual local 
degeneration; in spite of the patient's generally well-nourished 
condition, her lungs are starved. 

This is the reason why I have treated her with iron and 
quinine, in addition to the sethereal tincture of lobelia, which 
latter was ordered to alleviate the special symptoms at first. 
She is now able to breathe easier and to lie down in bed, but I 
am afraid she must be turned adrift on the cold world next 
week, for one can hardly expect to fit her for domestic service, 
and more pressing cases demand our beds. 

Bridget G., an unmarried servant, aged twenty-five, was ad- 
mitted on the 19th. She has the same sturdy build and bloated 
look as the last patient, and I cannot help thinking that most 
probably the pathological history of her case is the same. It is 
true that we cannot draw from her any account of pneumonia; 
but she is impenetrably stupid and ignorant, and hardly under- 
stands the English language, so that I do not reckon her answers 
to cross-questions as of much worth. She might easily have had 
slight pneumonia without recording in her memory anything 
which could lead us to a knowledge of it. Even in the former 
case, I doubt if the clinical clerk would have made out the oc- 
currence of pneumonia and typh-fever from the girl's tale without 
the aid of our former notes. 

Bridget's symptoms have been coming on three years, and in 
consequence the lungs occupy a larger space than Annie C.'s, 
overlapping the heart and rendering the cardiac region resonant. 
Her degree of dyspnoea, however, is not so great, nor is the or- 
thopncea so marked. I have often remarked that the asthmatic 
symptoms of emphysema are by no means proportioned to the 
large extent of the parts affected ; their severity rather depends 



296 . EMPHYSEMA OF THE LUNGS. 

on the rapidity with which the degeneration has advanced or is 
advancing. 

I have put her on a course of iron, for which I have already 
to-day told you my reasons. 

I have also had her cupped between the shoulders, as an expe- 
dient of immediate, though temporary, relief; and an expedient 
which the prominence of the venous crasis amply justifies in her 
case ; — she will soon recover the blood lost. 

She had been taking, by somebody's orders, some pills of 
squill and ipecacuanha every night. I continued them, in order 
to observe their influence. On leaving them oif she slept quite 
as easy as (she said easier than) when taking them, and I could 
detect no change in the quantity or quality of the sputa. So 
that expectorants are evidently of no use, an observation I have 
often had occasion to make in cases of emphysema. 

You have fairly exhibited in the history of these two girls the 
slow and gradual march of a degenerative lesion as a local affec- 
tion in a sanguine and otherwise healthy person. You see it 
caused by privations and injuries, rather than by any violent 
special exertion of the part. And you see how these causes act 
even in persons not constitutionally liable to such degeneration, 
namely, with great slowness and without threatening any immi- 
nent danger. It is different with leuco-phlegmatic persons. In 
their case the advance of degeneration is rapid and acute, and, 
if not checked by active tonic treatment, proceeds soon to its 
fatal termination. 

You will say this is a great advantage for persons of sanguine 
temperament. So it is. But it has its counterbalance. Degen- 
eration in them is much less amenable to treatment, especially 
to treatment by iron, which is the most valuable, than it is in 
the leuco-phlegmatic. Though rarer and slower, its march in 
them is unfortunately surer, when it has once begun. 



LECTURE XXIII. 
PULMONARY CONSUMPTION. 

Pathological data — The disease localized by morbid anatomy and 
auscultation — Pitfalls of this knowledge — Wot the presence, 
but the increase, of tubercle, is the chief point — Innocuous- 
ness of non-progressive tubercle — Object of treatment should 
be the organs of nutrition, not those of respiration — Food — 
Cough medicines — Appetite — Iron — Cod-liver oil — Alco- 
hol — Remedies for diarrhoea — Cachectic phthisis — Chlorate 
of potash — Delirium in the last stage of phthisis, how caused, 
and how to be treated — Specifics. 

[Clinical, /St. Marys, December 13, 1861.) 

I shall not °to-day detail any particular instances of pulmo- 
nary consumption. There are now, and always are, several in 
the wards, to which I have called your attention on points of 
diagnosis ; but it would be wasting the valuable time of a clinical 
lecture to recite their familiar phenomena, which, so far as they 
affect the treatment, are very uniform, and perfectly familiar to 
you I should presume. 

I take it for granted also that in the systematic course of lec- 
tures on medicine you have heard the following propositions, 
which seem to me to comprise the chief points contributed by 
pathology toward the treatment of the disease, and in proving 
which a great deal of time and thought have been worthily, be- 
cause usefully, spent. I shall assume — 

1. That the cause of the symptoms, of the disease, of its fatality 
in fatal cases, is the occupation by tubercle of vital organs, espe- 
cially the lungs; — 
20 



298 PULMONARY CONSUMPTION. 

2. That the tendency to the formation of tubercle resides in 
the constitution of the individual ; — 

3. That this tendency may be either hereditary or acquired, 
or both hereditary and acquired at once ; — 

4. That the circumstances which quickest develop this tend- 
ency are the same as contribute to anaemia, want of supplies 
for the formation of tissue — namely, starvation, bad air, depri- 
vation of light, exposure to cold without power of resistance, 
fatigue, previous illness ; in short, all depressants of the powers 
of life. 

Anatomy and auscultation have rendered us the enormous 
service of tracing out truly in death and life the organs chiefly 
injured in pulmonary consumption, and the nature of the injury 
done. What an incalculable advantage we have over our grand- 
fathers in this respect ! What a contrast between the dangerous 
confusion of various diseases under one head, the distinctions 
without differences spoken of in the writings of the by-gone age, 
and the almost finical precision of our diagnosis ! But do not 
stop here ; pathology must carry you on further, or you will have 
gained so little from science, that I doubt if your practice will be 
any better than your grandfathers', in spite of the treasure of 
additional knowledge you possess. Often, during our talk up 
stairs, I perceive signs of your considering the tubercle as "the 
disease" against which you have to direct the energies of your 
minds, and from which the patient has to be rescued. You want 
to do something to "stop" it, to "absorb" it, to "counter-irri- 
tate" or "evacuate" it; you seem to imagine that if you could 
take away that mass of cheesy matter which auscultation puts 
almost as clearly before your mind as if the ribs were transparent, 
your treatment would be perfect. 

And I fear that in this you might be upheld very often by the 
tone of medical literature, even of modern date. For example, 
I read in the " Cyclopsedia of Practical Medicine" that emetics 
are useful in the early stages of phthisis, by displacing and evacu- 
ating the tubercles from the lungs. Can the writer ever have 
really tried with a scalpel to pick out a tubercle from the pulmo- 
nary tissue, when he thus suggests the possibility of the gentle 



PULMONARY CONSUMPTION. 299 

pressure of vomiting effecting such a feat ? And I find the effects 
of cod-liver oil sometimes attributed, not with obvious common 
sense to its being an easily digestible oil, but to the minute 
traces of iodine which it contains. Yea, iodine itself has been 
given in long courses with the idea of bringing about the removal 
of the tubercles. 

I wish to put these notions out of your heads. What the pa- 
tient has to fear, is not the remaining of the tubercle in the body, 
but its increase. That which is once there has done its mischief, 
its path of ruin is past, the portion of lung which it has occupied 
is gone forever, and cannot grow again any more than an am- 
putated leg. The dissections of consumptives almost always 
show the cause of death to be a fresh formation of tubercle at no 
distant period, which has abridged the remaining organ to a de- 
gree inconsistent with life. A single deposit of tubercle to a 
moderate extent can almost always be recovered from. It is 
the continuous repetition of the morbid process which is so fatal. 
I cannot, therefore, too strongly impress upon you, that not 
so much the tubercle as the tendency to form tubercle, not the 
morbid matter but the diathesis, is that which should occupy 
your thoughts. 

When tubercle first takes its place in the pulmonary tissue, 
the lung feels a good deal inconvenienced by its presence; there 
is cough, inflammation round the foreign body, and condensation 
of the neighboring substance ; and this is accompanied by general 
ill health, arising from the sudden loss of part of the respiratory 
function, to which loss the system has not had time to become 
accustomed. These consequences are directly proportioned to 
the quantity of lung spoilt. They may be so severe as to cause 
death by what is called "tuberculous pneumonia," or by "gal- 
loping consumption," when a large extent of lung is very quickly 
rendered unserviceable. Or, when the injury is more gradual 
and slighter, they may be so insignificant as not to have attracted 
notice at all. The other day in a patient of mine who died of 
chorea dependent on a tubercle in the spinal cord, you saw at the 
post-mortem examination scattered tubercles in both lungs which 
had caused no symptoms at all during life, though they probably 



300 PULMONARY CONSUMPTION". 

had been there much longer than the tubercle in the less usual 
situation which proved fatal. And very often in persons killed 
by accident, apparently in the prime of activity and with no his- 
tory of any serious illness, you find crude tubercles, scars of 
former tubercles, and the chalk-like debris of tubercular matter.* 

Passing on to more agreeable evidence — we find people with a 
very large quantity of tubercle in the lungs, so large as to have 
almost proved fatal, who yet recover to a great extent from the 
mischief which it has caused. When once the lung has got over 
the shock produced by the presence of the first load of dead 
matter, the health recovers, and the patient (though imperfect in 
body of course) has only to fear a fresh crop. It is astonishing 
what enormous ravages may be made in the lung, and yet with 
the help of what remains how people will recover the health that 
has been lost. I dare say you may remember last summer a poor 
old woman sent to the hospital to die. There was in the left 
upper lobe a vomica, so large that there was " metallic tinkling" 
in it; and for some weeks I took the opportunity of teaching 
you this sound. You know from my lectures on diagnosis that it 
hardly ever occurs except in pneumothorax with perforation, and 
not always there ; that it is very rare in vomicae, and when present 
indicates a cavity bigger than your fist at least. So weakened 
was the patient by the loss of so much lung, that she was first 
unable even to feed herself, and quite soaked the bed with colli- 
quative perspirations. Yet, contrary to all our expectations, she 
lost her night sweats, gained flesh, walked about the ward, and 
finally walked home during my absence from London, so that I 
cannot say what was the exact state of her chest on leaving. 
But I will take for granted that the cavity remained unclosed, 
and probably will remain unclosed for the rest of her life. 

I say I take for granted that the cavity will remain unclosed 
for the rest of her life, from my experience of post-mortem ex- 

* In 556 autopsies of tubercular persons, which I found recorded in the post- 
mortem books of St. George's Hospital, during ten years, there was seen the so- 
called " cretaceous" matter in the pulmonary tissue in 65. See "Decennium 
Pathologieum," chap, v, sect. V, where statistical arguments are assigned for 
considering this solid substance to be really of tubercular character. 






PULMONARY CONSUMPTION. 301 

animations, which lead to the conclusion, that in cases of cured 
phthisis pulmonalis vomica rarely heal up, but that they become 
dormant and comparatively innocent, lined with a thick, pus-se- 
creting membrane, and thus separated from the healthy lung 
around them.* 

I <?an give also other and living evidence. — For example, R. 
S., a wine merchant aged forty-two, was, in 1846, under the 
care of several of the most experienced in chest complaints of 
the London physicians. He had a large vomica in the left apex, 
was excessively debilitated by it, and was sent home with the 
information that he could not live a month. ■ Well, he picked 
up strength and flesh, was enabled to return to his business, 
and, when I saw him in 1858, twelve years afterward, he was 
in fair healtk, and as able to do a moderate day's work as any- 
body I know ; but auscultation left no doubt that the vomica was 
still open in the lung, and that the small quantity of pus he 
expectorated came from it. 

In 1855, I advised a young man, with softening tubercles in 
the left lung, to accept a chance which he had of settling in the 
West Indies. Six and a half years afterward, he returned to 
England for a temporary purpose, and came to me about some 
symptoms not connected with his chest. I found that his vomica 
was still there, and secreting pus ; but that he had never per- 
manently lost again the flesh which a course of iron and cod-oil 
had put upon him. He had even had an attack of haemoptysis, 
and gone through yellow fever, without serious injury. 

As a contrast to such cases — and the way in which we lose 
sight of our patients prevents our multiplying them — as a con- 
trast to these where vomicae have become innocuous, compare 
those in which chronic consumption proves fatal. In the latter, 
a dissection always (accidental cases excepted) reveals, either in 
the lungs themselves or in other vital organs, a formation of 
fresh hard tubercle as the cause of death, besides the established 
vomica or the old masses of morbid matter. 

* Reasons are given in the chapter cited in the last note from my •' Decennium 
Pathologicum," in the Medico-Ohirurgical library, for believing that "chalky 
masses" in the pulmonary tissue are not the remains of vomicae but of hard 
ftubercle, which has dried up without softening. 



302 PULMONARY CONSUMPTION. 

It is clear, therefore, that it is the tendency to tubercle, and 
not the existing tubercle, which- we have to fear and to guard 
against ; and that for the successful treatment of consumption 
we must withdraw our minds from the* morbid anatomy of the 
locality to the fatal propensity of the constitution. 

To my mind, it is a great relief and rest to be able to map 
out by auscultation the exact extent of the mischief done, and 
to know that there is enough of the morbid change discovered 
to account for the severity of the symptoms. I feel then like 
a general who is acquainted with the exact position and whole 
force of his enemies, and is sure that the country will suffer no 
further loss if they can only be kept from advancing. 

In the case of chronic consumption, hope should never be 
entirely lost. If the remaining portion of lung has retained 
life so long, it can retain life longer, and the whole attention can 
be applied to its conservation. There is no question about the 
future conduct of the war, if only reinforcements for the enemy 
can be stopped in their march. 

To what quarter must we look for aid in this conservation ? 
I know you are disposed to turn first to the lungs. But if we 
inquire into the histories of those who have lived long with 
vomicae or tubercles, they are by no means found to have taken 
special care of their chests — they have not coddled or lived in- 
doors in even temperatures, hanging their lives on to their 
thermometers for fear of coughs : they have gone on with their 
professions or business. or work: they have not "laid a knife to 
their throat," but have eaten and drunk like other people, and 
have enjoyed the gratification of their appetites. A patient of 
mine, over fifty, with copious pyoptysis and condensed lungs (of 
probably a tubercular nature) from his youth, has kept hounds, 
broken his bones like other Nimrods, contested county elections, 
sat in parliament, enjoyed his champagne and other good things, 
but never allows any doctoring of his chest. An examination of 
it is a favor, as a contribution to science. 

Nor is it only when tubercle is established that it may be 
arrested by exposure of the body to active change ; even the 
tendency may be averted. I examined for insurance a few 



PULMONARY CONSUMPTION. 303 

weeks back, a gentleman aged fifty-five, the second of a family 
of eleven in whom phthisis was hereditary. Circumstances 
have caused the three eldest to rough it in the world ; they have 
traveled and worked, and now when wealthy, they are healthy, 
active sportsmen. The seven youngest were coddled and petted, 
and all died of consumption under twenty -five. 

The necrological statistics of the phthisical in the two sexes 
corroborate this deduction. Although males are more liable to 
tuberculosis than females, yet they are less liable to have that 
tuberculosis exhibited in the lungs. (See " Decennium Patho- 
logicum," chap, iv.) Now in all classes of social life, women 
are the least disposed to exert and expose their lungs ; they are 
more ready to invalid themselves ; and in the lower classes, 
whence these statistics are taken, they do not wear low dresses 
or tight stays (to which habits some have attributed consump- 
tion). Yet we find that tubercle with them takes the direction 
of the spared organ. 

You may perhaps say, " This spared organ is a most important 
one : I will sacrifice the others to the possible chance of saving 
it." But consider — what is this tubercular matter ? It is not 
anything peculiar to the lungs, but may arise from degenerated 
nutrition — the inferior development of life — of any part, and 
may occur in any part. Now, excepting my glands, many of 
which I could easily spare, I should prefer having it in my lungs 
to any other part of my body ; for I know that I can live with 
a good deal less pulmonary tissue than nature has given me. 
But I cannot live with it in my brain, or my heart, or my ali- 
mentary canal, of which I have only one. So that if tubercle 
is to exist at all, I really do not know that we should look upon 
it as a misfortune when it occurs in the chest, as it is safer there 
than in most parts of the body. 

If then care bestowed upon the lungs and special coddling of 
them increases the danger of tubercular tendencies, as the above 
arguments clearly show; and if, supposing that special medication 
could keep tubercle out of the lungs in particular, no advantage 
is thus gained — to what would I have you turn ? 

Leave the respiratory organs alone, and direct your thoughts 



304 PULMONARY CONSUMPTION. 

to the organs of nutrition, the stomach and bowels, which will 
receive with thankfulness and return with interest any care you 
bestow upon them. 

It is truly by aid of the digestive viscera alone that consump- 
tion can be curable. Medicines addressed to other parts may 
be indirectly useful sometimes, but they more commonly impede 
the recovery ; whereas aid judiciously given in this quarter is 
always beneficial and usually successful. 

The chest is the battle-field of past conflict, the stomach the 
ripening ground for new levies of life. 

Your aim should be to get the greatest possible amount of 
albuminous food fully digested and applied to the purpose of 
the renewal of the body, at the same time that the renewing 
agencies are brought to their highest state of efficiency. In 
this way a healthy cell-renewal takes the place of that morbid 
imperfect cell-renewal which appears in the shape of tubercular 
matter. 

With this view I shun, as far as I can, all those " potent herbs 
and baneful drugs" which may be classed together as " cough 
medicines," meaning antimony, ipecacuanha, and squill especially. 
I avoid also mercury, purgatives, and neutral salts, which are 
debilitants. Where the heart is thin and weak, digitalis is some- 
times useful, by regulating and calming its action • but as a rule 
it is injurious, by reason of the nausea and loss of appetite which 
it causes. 

The appetite should be the great object of your care. You 
will often find it sadly wanting ; and where that happens, the 
mucous membrane of the stomach and bowels should be braced 
up by quinine and strychnine. The latter acts quickly, and 
may be added to the other medicines from time to time ; but the 
former is most permanent in its effects, and should be begun at 
once, and continued through the whole process of medication, 
till the appetite equals or exceeds that of a healthy person. 

Iron, again, you will find a most powerful ally. The increase 
in the hgematine of the blood which follows its use is all-im- 
portant ; for thus you supply to the tissues the true life-giving 
medicine — red blood. Begin iron in small doses, and gradually 



PULMONARY CONSUMPTION. 805 

increase it till you have found the full quantity the patient can 
take, and then continue to administer rather less than that, so 
as to leave room for an occasional augmentation according to 
circumstances. Where you give digitalis, make it a rule to add 
iron and sometimes strychnine to the dose, as you thus get the 
full advantage of the digitalis, and shirk some of its possible 
evils. Iron prevents nausea, and strychnine co-operates in 
strengthening and regulating the action of the weakened heart 

When the repugnance to eating is extreme, adopt the plan you 
so often see used in these wards with success, of giving milk in 
small and very frequently repeated doses. Nutrition has a habit 
like that of arguing in a circle ; food creates the desire for food — 
of course, by strengthening the digestive organs ; and thus, after 
a few days of milk diet, the patients will voluntarily ask for 
meat, and enjoy as a luxury that which a short time before 
excited the greatest disgust. If you find the milk lie long in the 
stomach and produce heartburn or acid eructations, add lime- 
water or soda-water to it. The first is the cheapest, the latter 
the pleasantest. 

Cod-liver oil will also often, like milk, create an appetite. But 
as a rule, especially in private practice, it is well not to commence 
it too soon ; for the nastiness of the taste and feel is hard to get 
over at first, and it is much easier to take it when the appetite 
has begun to be renewed. Then it is not felt as a hardship even 
to begin, and in a short time patients will get really to like it. 
And they will like it, not merely as reasonable men like that 
which does them good, but irrespectively of such knowledge they 
will find it nice to the palate. Thus children, who always hate 
being done good to, will still often take to their oil with gusto. 
And as a proof that exalte^ reason has nothing to do with the 
preference, the same thing has been observed in brutes. A 
clerical friend of mine had a consumptive Skye terrier, which he 
treated secundem artem with cod-liver oil. At first the poor 
beastie abhorred it, and looked sad before and after each dose ; 
but in a short time he began to lick his lips after it, and if he was 
forgotten, would go and beg more canino at the door of the cup- 
board where it was kept. 



306 PULMONARY CONSUMPTION. 

The best sort of cod- oil is the most agreeable, the clearest, the 
sweetest, and the most scentless — that, in fact, which is thor- 
oughly free from extraneous dirt. The oil from the same fish, 
formerly used by curriers, was sold for their use cheap and foul, 
and no doubt was quite good enough for manufacturing pur- 
poses ; but it must excite a very natural disgust in any one but 
an Esquimaux or a whaler, I should think, for it stinks like old 
train-oil. Its low price wholesale allows of certain firms spending 
large sums in widely advertising it as a superior form of drug ; 
but I strongly advise you never to practice the " brown-oil" 
(as the name runs) ; it is never beneficial where the pure oil fails, 
and it often and often makes the patient protest he will on no 
consideration take it again. The mode of manufacture which 
causes the difference of the "brown" and " pale" oil is described 
in an article of the " Medico-Chirurgical Review" for January,' 
1856, and is quite enough to prevent any reader of delicate per- 
ceptions ever ordering or taking it again. 

The best plan is to give at first a teaspoonful, and afterward 
two teaspoonfuls thrice a day, floating on the quinine or iron 
mixture to which the patient has already become habituated. I 
think an ounce a day is enough to administer as the full dose, 
and need not be exceeded. If the patient absorbs all that, you 
may be quite satisfied ; and more will be apt to turn rancid, and 
cause indigestion — the worst foe of the phthisical. The best 
time to take it is a tthe greatest distance from meals, as thus a 
sort of additional meal is gained, and food and physic are not 
confused ; but if your patient likes any other time better, on 
account of taste or business, do not stand in the way of his fancy. 

The effects of cod-liver oil become less and less a marvel, the 
more we know of physiology. The. instinctive desire shown by 
all nations for an oleaginous diet, and their association of sub- 
stances of this nature with proverbial ideas of happiness in all 
ages, show the value of a certain amount of it to man's comfort. 
The " butter and honey" of the prophet, used as a phrase for 
royal food, and the constant reference in the Bible to oil as a 
luxury (though it could have been no rarity in "a land of oil- 
olive")— these are sufficient to prove its estimation among the 



PULMONARY CONSUMPTION. 307 

Hebrews. The Hindo laborer, when' he devours his gallon of 
rice for a meal, will spend all the pice he can get on the clarified 
butter of the country ; and " as good as ghee !" is his expression 
of unqualified admiration. It was a mistake in Baron Liebig to 
state that oily foods are disgustful to natives of hot climates. All 
races of men require them and seek after them ; and the taste of 
the Esquimaux, so often quoted, depends mainly on the abundant 
supply of the article which the sea places at his disposal, coupled 
with a scantiness of other provisions. Throughout mankind there 
is an instinctive appreciation of the importance of this aliment, 
independent of accidental differences of nation .or locality. It 
seems felt to be, as science shows that it really is, a necessary 
material for the renewal of the tissues, and the desire for it 
becomes synonymous with a desire for augmented life. 

An easily assimilated oil comes, in fact, into the short list of 
directly life-giving articles in the pharmacopoeia ; for it is itself 
the material by which life is manifested. Hence, under its use, 
beneficial influences are exerted throughout the whole body ; old 
wounds and sores heal up ; the harsh, wrinkled skin regains the 
beauty of youth ; debilitating discharges cease, at the same time 
that the normal secretions are more copious ; the mucous mem- 
branes become clear and moist, and are no longer loaded with 
sickly epithelium ; the pulse, too, becomes firmer and slower — 
that is to say, more powerful, for abnormal quickness here is 
always a proof of deficient vitality. Such are the effects, per- 
fectly consistent with physiology, of supplying a sufficiency of 
molecular base for interstitial growth. 

The addition of a small quantity of alcohol will often enable 
the oil to be absorbed more readily. This is a principle well 
understood by growers of live stock for prizes at agricultural 
shows, who, by the addition of fermenting grains or spirits to the 
animal's food, often fatten it more quickly. The addition there- 
fore of wine, whisky, tincture of orange-peel, or of any other 
harmless bitter to the medicine, is rational, and may be freely 
conceded, if the patient finds it agreeable. 

The liberal use of it as a remedy or preventive is a different 
question. 



308 PULMONARY CONSUMPTION. 

In my opinion alcohol is not only useless but injurious to the 
consumptive, excepting for its beneficial action upon the mucous 
membranes. It arrests and obstructs the vigor of vital action ; 
by it growth is checked, as we see practiced in animals kept 
small for artificial purposes, and in men who have> from youth 
habitually indulged in ardent spirits. Under its use renewal 
goes on slower, as we know by the diminished excretion of urea, 
water, bile, &c. (see Dr. Booker's "Experiments," and the con- 
cluding lecture in this volume), and we can hardly therefore 
reckon it advantageous where the chronic renewal of vital 
powers is our primary object. 

But you may ask how are to be explained cases like the fol- 
lowing, in which to all appearance alcohol seems the preservative 
of life. 

J. P., a butcher, remarkably strong and stout, was first at- 
tended by me for delirium tremens, which he had suffered from 
several times before, and was always well in the interval; an 
attempt to becomea teetotaller was immediately followed by gal- 
loping consumption. 

J. A., a brewer, came to me last year about indigestion and 
pimples (acne rosacea) on his nose and face ; I urged him to give 
up brandy-drinking before breakfast and between meals; and I 
find now a developed vomica in his lungs, of which previously 
there was no evidence. 

You may cite instances such as these, and attribute the 
vomica to the omission of alcohol, which therefore you may. 
represent as a direct preservative. I think you would be 
wrong. 

I confess I do not take such cases as mere coincidences, but 
I explain them in a way by no means corroborative of the idea 
that spirit-drinking keeps off consumption. I think that alcohol 
acts as an ansesthetic, and prevents the system from resenting 
the presence of the tubercles ; then, when it is left off, they act 
with doubly deleterious effect on the body, unprepared by their 
gradual increase to bear them as it were by habit. The quon- 
dam tipler is then in the same relative position as one in whom 
there is a large sudden development of the morbid matter; 



PULMONARY CONSUMPTION. 309 

for the existence of the morbid matter unexpectedly becomes 
known to the system, and its ravages suddenly taken notice of. 
Thus instead of really checking tubercular disease, the alcohol 
has acted merely as a mask, behind which the evil has gone on 
unawares. 

What should you -do in such cases as those above related ? 
Should you advise a return to drinking habits ? I think not ; 
for though the symptoms are somewhat lightened thereby, this is 
merely a misty cloud of anaesthesia which stands between the 
patient and his pain, and I doubt if life is prolonged. More- 
over, it is possible to adopt measures as immediately effectual, 
while certainly offering more prospective advantages. In the 
last case which I quoted, after a certain struggle with bron- 
chitis, night-sweats, and emaciation, weight and strength are 
being gained under cod-liver oil and quinine, although the 
allowance of alcohol is reduced to that of a temperate man. So 
to such remedies I advise you to trust in all like cases. Here, 
as ever, the appetite must be your index ; the stomach must be 
the viscus whose health is to be your care. 

In advising foreign travel, again, take the stomach for a guide. 
At the dreary time of the English year, when your patients can- 
not get enough light and exercise to give them an appetite, let 
them seek those sunny climes where the winters are the holidays, 
the joyous seasons for out-of-door employment. Madeira is the 
best. The next is that lovely Mediterranean shore recently 
annexed to France, from Cannes to Mentone ; and after that 
comes a long list of localities highly praised by their inhabitants, 
but with a more uncertain climate. 

Instead of naming one place after another, and thus risking 
offense to a large number accidentally omitted, I prefer to give 
you a simple common sense rule by which you may help your 
patients to make the best use of the winter season. 
* In choosing a home for your consumptive, do not mind the 
average height of the thermometer, or its variations ; do not 
trouble yourself about the mean rainfall ; do not be scientific at 
all, but find out from somebody's journal how many days were 
fine enough to go out forenoon and afternoon, — that is the test 
you require, and by that you may be confidently guided. 



310 PULMONARY CONSUMPTION. 

Do not suppose all is done when you have chosen a climate. 
Your responsibility is by no means ended; you must be careful 
in enforcing a right use of the climate. If your patients, from 
distaste of foreigu habits, from pining after home, or other causes, 
take to moping in-doors, or find themselves overwearied on going 
out, the sooner they return to England the better. They are 
getting no good, and they are running the risk of diarrhoea, low 
spirits, hysteria — or still worse, of failing so much, that they 
cannot return home, and must remain to die, "by strangers 
honored, and by strangers mourned." 

But if they write you word that they are boating, riding, 
swimming, sketching, catching lions in Algeria, or butterflies in 
Madeira, you may congratulate yourself on having added perhaps 
months, perhaps years, perhaps lustra, to their lives. 

Next to the stomach, the bowels claim your main care. Of 
course, during this course of lectures, in which I am impressing 
upon you the principles of restorative medicine, it is needless to 
say that in pulmonary consumption you are to shun artificial 
purgatives. But I had better remind you of the importance of 
being on your guard against natural diarrhoea. Do not allow it 
to go on an hour longer than you can help. The best remedies 
are sulphate of copper, hsematoxj^lum, and opium. Chalk mix- 
ture will sometimes act well ; but, if it fail, you have lost valuable 
time ; so, if you follow custom in beginning with it, do not be 
obstinate in the continuance of your remedy. The sulphate of 
copper may be begun in doses of one-fourth of a grain, and in- 
creased up to two grains, if required to be persisted in. The 
hsematoxylum may be given as an extract from four grains up to 
any amount required, but should not be mixed with the copper, 
or you produce an ink. If you give both, let there be three hours' 
interval between them. 

You see almost daily cases of consumptive diarrhoea checked 
sometimes for a season, sometimes even permanently in patients 
whose disease is too extensive for recovery. This is doubtless a 
great point gained, and some time added to life. But more than 
this, I believe that the tendency to deposit tubercle also is some- 
times arrested by arresting the bowel-complaint. Just after 



PULMONARY CONSUMPTION. 311 

Lady-day 1861, Miss Harriet B., aged thirty, whose "father and 
mother had both died of decline," was placed under my care by 
Dr. Buckell, of Chichester. She had evidence of a small focus 
of tubercle in the apex of the left lung, producing pain, dullness, 
and crepitation (from the partial condensation of the lung round 
it) but no marked pulmonary ailment. I thought that the quantity 
of tubercle was slowly increasing from week to week. What she 
complained of, however, was emaciation and diarrhoea, ac- 
companied by the passage of pus and sometimes streaks of blood 
in the mucous faeces. She was soon relieved of this by appro- 
priate remedies ; and with a store of haematoxylum and copper 
was able to go on a long summer visit to some friends. I heard 
of her as going on well, and did not expect to see her again, or 
to make her case, available for science. But as she returned 
through London in September, proclaiming herself quite well and 
stout, I had an opportunity of examining her chest again ; and 
much to my delight was it that I did so. To my surprise, I 
could detect no disease at all in the lung ; so that, instead of 
increasing, as I had feared, the pulmonary tubercle had become 
dormant, solely by the cure of the bowel-complaint. Not all 
cases do as well as this, but still what has since befallen may 
befall again, and it is the surest road to success to hope for it. 

(Clinical, St. Marys, June 7, 1862.) 

In some cases of consumption there is a considerable amount 
of cachexia, the gums become spongy, or whitlows form on the 
fingers, or there are various kinds of skin diseases. This hap- 
pens usually in consequence of low living, damp, and depression 
of mind. 

There is now in Victoria Ward a girl of sixteen, who was 
transferred from a surgical ward. She was at first in a deplor- 
able condition; she had been admitted for impetigo,* with which 
her cheeks and nose were covered, while the pads of her finger- 

* Impetigo = " a superficial formation, consisting mainly of pus from the de- 
nuded connective tissue of the corium, without external exciting causes." 
Eczema = " the same of serum" 



312 PULMONARY CONSUMPTION. 

tips and nails were sore and purulent from the same eruption. 
Yet the impetigo did not account for colliquative night-sweats, 
extreme emaciation, and weakness so great that she could not 
raise herself in bed : these symptoms were explained by dullness 
at the apices of the lungs and localized rales, indicative of tuber- 
cular condensation. Some thought there was a vomica at one 
apex, on account of the cracked-pot sound on percussion, but it 
was a doubtful point — the cracked-pot sound is a very fallacious 
sign. She did not behave as if there were a vomica, for she has 
been gaining strength and flesh daily up to this time. My reason 
for recalling this case to you is to notice that, in spite of .tonics 
and high feeding, before she came under my care she had been 
getting weaker and weaker. The only change I made was to give 
with her tonic mixture half a drachm of chlorate of potash daily 
in some cod-liver oil — I confess with but little hope that she 
should revive. I was never so struck before by the directly 
vitalizing force of this salt upon connective tissue. In a fortnight 
her " flesh came again like unto the flesh of a little child," as the 
Hebrew historian beautifully expresses it ; the clear doll-like 
complexion of face and the pink babyish finger-tips are very 
pretty. And I have no doubt that a like quickening has gone 
on in the skins of the inside — the mucous membranes — so much 
strength and appetite has she gained. 

This case shows you when to give chlorate of potash in con- 
sumption with hope of profit. And I am glad you have the op- 
portunity of seeing this, because a short time ago chlorate of 
potash blazed forth as a cure for phthisis in general ; and if you 
have tried and found it wanting in some ordinary instance, you 
might be tempted to treat with undeserved contempt a medicine 
of really great service in proper cases. 

(Clinical, St. Marys, February 6, 1864.) 

On my last admission day, January 29, there were received 
under my care two very distressing cases of consumption. Both 
were in the extremest state of emaciation and exhaustion from 
suppurating vomicae in the lungs, and so far presented a spectacle 



PULMONARY CONSUMPTION. 313 

which is sadly familiar to the medical man. In addition, the 
woman was purple in the lips and face from intercurrent pneu- 
monia, the man was in a cold sweat and had diarrhoea. But the 
symptom exhibited by both in common, which leads me to 
mention the cases to-day, is one not quite so usual as these, yet 
sufficiently usual to make it of practical importance. I allude 
to delirium. The man. got temporarily somewhat better of it 
after a few days' residence in the hospital, so that his mind 
wandered only at night, but the woman has been disturbing the 
ward with her continuous ravings, has been" very violent, exert- 
ing her small remains of strength to throw the beef-tea at the 
nurse. She uses such abominable language that it has become 
necessary to place her in a room by herself. 

Delirium at the latter end of exhaustive diseases is a sign of 
the participation of the nervous tissue in the destruction which 
is going on among all the tissues of the body. It answers to the 
convulsions and obtuseness of sense, which M. Chossat observed 
in animals starved to death.* The nervous system, being the 
ultimum moriens of the body, suffers last, but does suffer in the 
end. 

This delirium is commonly accompanied by deafness, and is 
so accompanied in the two cases before us. I cannot say I have 
been able to trace a corresponding deficiency in the organs of 
sight, but certainly the taste and general sensation are deficient. 
The pain in the chest and suffocation, which the poor woman 
complained of on admission, are denied now that the raving is 
worse, and she does not appear to know food from medicine. 

The immediate cause, to which I have most usually seen 
occasion to attribute it, has been unwonted and excessive bodily 
exertion, at a time when extreme rest constitutes the only pos- 
sible means of economizing the vital power. I have no doubt 
but what it was the being brought out of their beds to the hos- 
pital, which made these patients so much worse directly on their 
arrival, and which threatens to shorten their lives. 

In those who die, no morbid change in the nerve substance is. 
visible after death, though the symptoms during life generally 

* See before, pages 45-49 of this volume. 
21 



314 PULMONARY CONSUMPTION. 

cause it to be carefully looked for. This fact is familiar enough 
to those who have the inestimable pathological privileges of a 
public institution : but I think it is often unknown to others ; 
and consequently the natural connection in their minds between 
the increase of symptoms and the spread of tubercle in consump- 
tive cases is apt to lead to their assigning the delirium we are 
considering to a development of tubercle in the brain. Two 
months ago an old gentleman in the last stage of senile phthisis 
was brought up from the country by his family, contrary to the 
excellent advice of their own medical man, to obtain "a London 
opinion." I believe they had already taken him to one physician 
previously, when he arrived, excited in mind and worn out in 
body, in my study. I felt much relieved when a glass of Madeira 
enabled him to be got back to the carriage, for I should not 
have been much surprised at his dying in my house ; and you 
may easily imagine that I rebuked the folly of his friends in 
strong language. However, he did get home. But very soon 
he became delirious and raving, as I learned by letter ; and I 
found that this delirium was attributed by those who attended 
him in the country to tuberculosis of the brain. The idea is a 
natural one, but it might have injured the patient had it influ- 
enced the treatment. His death in delirium was indubitably due 
to the almost superstitious folly of his friends in bringing him up 
to London. 

As to treatment, opium, wine, and continuous nutriment seem 
indicated, and to be of some use ; but such cases of extreme dis- 
ease are not usefully illustrative of medical regimen. The man 
has been better since he began cod-liver oil and quinine, and 
perhaps the nourishing thus the nervous tissue, if the food can 
be assimilated, is the best application of restorative principles. 

{Clinical, St. Marys, May 10, 1862, $c.) 

sfc * *. * ^ H« 

A few words as to specifics for consumption. Some years ago, 
Dr. John Hastings proclaimed u naphtha" as an unerring cure. 
Some people tried it, and soon learned that it was applicable at 



PULMONARY CONSUMPTION. 315 

all only in cases where alcohol was beneficial, and even to such 
patients they found that the purer and wholesomer forms of 
alcohol in daily use were both more useful and more acceptable. 
All the advantages of the remedy had been in the hands of the 
public in a pleasanter form centuries ago. Determined at last 
to try a virgin substance — 

— " integros accedere fontes 
Atque haurire " — 

the same gentleman has lately announced that serpents' dung 
now succeeds to the throne where naphtha lately reigned. Our 
rude forefathers in art administered many curious things ; the 
ashes of toads, the urine of boars, live spiders, human liver, 
human ordure, the skull of a murdered man, the blood of the 
patient's father, and other gatherings from» witches' caldrons, 
are in their lengthy pharmacopoeias, and are many of them 
stored in that interesting collection of ancient articles of materia 
medica at the College of Physicians. Their intention was to 
drive out the devil by disgusting him. But I do not think that 
they ever hit upon the bright thought of using the very dung 
of the accursed type of evil, that as he indignantly "goes out," 
he may say : 

" That eagle's fate and mine are one, 
Who in the shaft that made him die 
Beheld a feather of his own 

Wherewith he wont to soar so high." 

I really believe this expansion of the idea to be quite original. 

Good coprologists tell us that the united excreta of snakes 
consist mainly of lithate of ammonia — an unattractive substance, 
which persons familiar with physiology believe to be harmless. 
I rested satisfied with that belief till I heard Dr. Hastings, 
when arraigned before a public court of justice for avaricious 
malpraxis in knowingly administering inert remedies, depose 
positively on oath that he held what he administered to be a 
powerful physiological agent. His powerful physiological agent 
was made by dissolving (i.e. destroying) sixteen grains of boa 
constrictor's ejecta in a gallon of water by the addition of bro- 
mine. Such a solemn affirmation was not to be lightly treated, 



316 PULMONARY CONSUMPTION. 

and after that I could not feel justified in believing faeces to be 
useless till I had tried them. I procured forthwith a sample 
from the secretary of the Zoological Society, and caused to be 
made a quantity of the so-called a solution" under the name of 
" mistura pythonis," and you have seen me order it pretty often 
since in cases where, no drugs being required for a time, I felt 
myself justified in so doing. But instead of half an ounce, 
which w T as said by the witness to be so active, I have given two 
ounces three times a day. You have seen that its effects are 
exactly the same as those of so much ditch-water. 

Such is the fate of specifics for phthisis — ex uno disce omnes 
— and lucky is the public if all specifics are as innocent as 
snakes' dung. 

But do not let us part without a moral, or be satisfied with 
merely laughing at a delusion. Bemember, you are acting no 
better than the vaunters of vain specifics when you vaguely pre- 
scribe one thing or another, even of known or acknowledged 
power, because you have heard of its being "good for consump- 
tion." The time which is lost in trying this and trying that 
remedy is lost forever. You have no warrant for supposing 
that there can be any specific for that complex morbid state 
which causes phthisis ; you have no warrant for substituting a 
vague search after such specifics for rational treatment ; nor can 
you justify yourselves for standing in the way of the patient 
getting his chance of a renewal of his waning life by the un- 
sparing use of restorative agents. 

The proper persons upon whom to try the effects of new x 
remedies in the first place are not the sick, but the healthy or 
nearly healthy. If no obvious results follow the use of full 
doses by yourself or another free from present illness, you may 
be pretty certain the same will be the case with your patients. 
There are always to be found in hospitals specimens of malin- 
gerers and "old soldiers," and convalescents, upon whom it is 
quite safe to try these experiments under proper supervision, so 
as to satisfy any doubts you may have. Or if you have no doubts 
to begin with, you will thus gain a right to make the shortest 
and most telling answer to inquiries, " How does such and such 
a cure succeed?" "I've tried it and it is useless." 



PULMONARY CONSUMPTION. 317 

You should make it a rule absolute, that objective phenomena 
rather than subjective are to be taken as tests, and that all things 
are to be " delivered in number and weight," according to the 
sage advice of the Son of Sirach. For instance, if you were 
examining the action of quinine, the changes of temperature 
must be estimated by the thermometer, the changes of urine in 
the laboratory, the action on the skin from the amount of per- 
spiration. And you must not waste time by performing as 
tests experiments which do not admit of physical or arithmetical 
proof. 



LECTURE XXIY. 

THORACIC ANEURISM. 

First case of aneurism, probably of the innominata — Reasons for 
diagnosis — Aortic valvular murmur accounted for — Prob- 
able abnormal position of artery — Prognosis unfavorable 
— Second case — Aneurism of aorta and its treatment — 
Blood-letting and low diet — Pathology of aneurism — Object 
of treatment — Favorable prognosis — Two cases of favorable 
result of treatment — Fatal case of aortic aneurism — Rup- 
ture of sac into the pleura in a healthy working man — 
Length of time a patient may live with a ruptured aorta an 
encouragement to treatment — Case of aneurism compressing 
the trachea, producing congestion of the lungs, and so fatal 
— Actions of bleeding, leeching, and digitalis — Action of 
digitalis on other involuntary fibers as on the uterus in 
menorrhagia, and on the bladder in incontinence of urine. 

{Clinical, St. Mary's, January 5, 1861.) 

I take the opportunity of having two patients in the wards 
affected with aneurism of that sort which alone comes under a 
physician's case, viz., thoracic aneurism, to call your attention 
to the medical aspects of the lesion. 

The board admitted, yesterday, into Victoria Ward a young 
woman of twenty-two, who has been a patient of mine in the 
Lock Hospital. She has had syphilis on and off ever since the 
age of fourteen ; and though the eruptions and sores are now 
healed, her health is much broken, and she is stunted and 
weakly. She applies at St. Mary's not for her old complaint, 
but on account of palpitations, and pain across the front of the 



THORACIC ANEURISM. 319 

chest, which she states that she has felt for three years, but 
which lately had got much worse. She also frequently suffers 
from giddiness and fainting ; and last Sunday was carried out of 
chapel in a dead swoon. A message has just come to say that 
on account of one of these attacks she is unable to come down to 
the theater, as I bade her. 

She has often a difficulty in swallowing food, especially solid 
food. 

She states that she has very partial use of the left arm ; and, 
on examination, it is smaller in girth to a marked degree, and 
the muscles are flabbier than on the right side. No pulse can 
be felt at the left wrist, nor at the bend of the elbow, nor on the 
inner side of the biceps. The axillary artery can be felt beating 
very feebly above the collar-bone. 

In a marked contrast to this stands the right side. The pulse 
at the wrist is natural, and above the collar-bone may be per- 
ceived a strong pulsation, and at the origin of and for an inch 
or more along the carotid artery a very distinct thrill. In the 
hollow above the sternum the same pulsation is even stronger, 
and throws forward the trachea, when you press upon it with 
your finger. 

With a stethoscope a purring whiz is heard in the same situ- 
ation as the pulsation is felt. A murmur is heard also at the 
upper part of the sternum, and is particularly loud on the level 
of the fourth costal cartilage, where it sometimes has a musical 
tone. There is no dullness on percussion beneath the clavicle. 

My diagnosis of this case is, that she has an aneurism of the 
ascending aorta at the part where the innominata is given off, 
and that this lesion involves the innominata and the origin of 
the carotid artery. I do not think it an enlargement of the 
innominata alone, because of its being situated so much at the 
back of the trachea as to throw the tube forward by its pulsations 
and also to press upon the oesophagus, and interfere with deglu- 
tition. Besides, in the only case I have seen during life of pure 
aneurism of the innominata, proved to be so after death, the 
tumor was smaller and rounder, and pointed more distinctly in 
the supra-clavicular hollow. 



320 THORACIC ANEURISM. 

You have here nearly all the signs of aneurism of the aorta 
— (1) pulsation ; (2) whiz ; (3) impaired deglutition ; and (4) 
impeded circulation. 

But you may say there is the same whiz at the aortic valves. 
What is the cause of that ? It is not, I think, produced directly 
by aortic aneurism, but it is produced by the same original 
cause. Aneurism forms because there is a friability or loss of 
elasticity in the coats of the vessel, due generally to a deposit 
of white opaque matter and to a partial degeneration of them. 
What is more likely than the existence of the same disease in 
the aortic valves? 

Now I come to the puzzling part of the case. You will ob- 
serve that the right axillary artery is quite free ; there is quite 
an open passage through it to supply the radial at the right 
wrist. Yet it is in this supra-clavicular space that we have the 
pulsation and whiz; whereas the left axillary, though it has 
normally nothing to do with the innominata, is not supplied 
with blood, and the left arm is atrophied. 

I can account for this in one way, which I might as well detail, 
though it is more a matter of curiosity than of business. (I do 
not bind you to accept the interpretation ; and if any of you 
fresh from the anatomy school can suggest a better, I shall 
receive it with pleasure.) In many beasts, in the ruminants and 
solidungula, and in some pachydermata — as for instance the 
hog — the aorta divides into two branches, the ascending giving 
off the two subclavians and the two carotids, while the other 
turns backward and becomes the descending aorta. On this has 
been founded, by the earlier anatomists, the popular division of the 
aorta into " ascending" and "descending," a division awkward 
in the human species, but exceedingly applicable to the domestic 
animals w T hence the ancient men of science learnt their anatomy. 
It is by no' means impossible that the patient before us may have 
a malformation, which is an approach to this lower condition of 
animal life — a malformation, of which specimens may be seen in 
many museums ; namely, where the left subclavian, as well as 
the right, is given off by the innominata, and has to cross over 
the arch of the aorta to get to its work ; and in this crossing it 



THORACIC ANEURISM. 321 

would be interfered with by the tumor of the top of the arch. I 
cannot otherwise unravel the enigma, as the tumor is not large 
enough to obstruct a normal left subclavian. As an argument 
in support of the explanation, I may mention that the patient 
has a .congenital deficiency of the reproductive organs, curious in 
a social point of view to find in a person of her degrading habits, 
for she is a common prostitute. She has no uterus, the vagina 
ending in a short cul-de-sac. A malformation in one part is a 
probable argument for it in another. 

This aneurism presents several points which lead me to pro- 
nounce an unfavorable prognosis. First. It is in the ascending 
part of the aorta. Now, you will find that almost all aneurisms 
of the ascending aorta are rather dilatations than aneurismal 
sacs. They have no sharp edge opening out suddenly into a 
distinct bag. And these dilatations are more difficult of cure 
than the sharp-edged sacs, because there is a clear stream 
through, and no back current, so that you cannot get clots to 
form in them. Secondly. The absence of clots is confirmed by 
the strength of the thrill. Thirdly. The supply of blood to the 
brain is seriously diminished, as is shown by her fainting fits. 
Fourthly. The impeded deglutition and the suspected malforma- 
tion are discouraging. Fifthly. She is a poor anaemic woman, 
reduced by poverty, syphilis, and mercury to a very low state. 
She will not bear lowering treatment, I am sure. Sixthly. She 
is said to have, like most of her unhappy class, a violent temper; 
so it will be difficult to detain her in the hospital, or to keep her 
circulation quiet while there.* It, is doubtful how far we shall 
be able to apply the treatment suitable for the disease, and how 
far it will prosper, if applied. What that treatment is, I shall 
best tell you after the next case. 

Henry E., a negro, aged twenty-one, came under my care two 
months ago — viz., on November 9. He is now a commercial 
traveler, but during the Crimean war was a sailor in a transport, 

* Very soon afterward it was necessary to turn ber out of the hospital for 
gross misconduct, and T have not been able to find what became of her. As she 
is corporeally rather a remarkable person, perhaps this notice may bring the 
desired information. 



322 THOKACIC ANEURISM. 

during which time he got a severe blow on the back of the neck 
from a " derrick." He says he never had cough or shortness of 
breath, and was always "strong in the chest," till he began to 
feel a pain there in August, especially between the left nipple 
and the collar-bone. This pain increased gradually, though 
intermittingly. Three days before we saw him, while he was at 
his tea at Windsor, it suddenly increased very much, and he 
says he felt "as if something was going up and down from his 
heart to his arm." He fell down, was struck dumb, and found 
that he had lost the use of the left arm. On his admission, it 
was found that the pulse in that wrist was much weaker than in 
the right, and there was loss of power, though not absolute 
paralysis throughout the limb. The throat was externally 
swelled on the left side, and the carotid could scarcely be felt. 
There was considerable swelling of the whole mammary and 
infra- clavicular regions, in which latter also there could be dis- 
tinctly made out comparative dullness on percussion. This 
dullness was more distinct on the third rib than immediately 
beneath the collar-bone. . On applying the stethoscope to the 
third rib, a distant whizzing murmur could be heard, which in- 
creased in intensity in nearing the shoulder, and was less loud 
toward the sternum. There was no pulsating tumor, and the 
lung-sounds were natural, except perhaps rather more bronchial 
on the left side than on the right. There was a breathing pul- 
sation in the left jugular vein. 

The signs of aneurism were not so distinct as in the last case, 
because it did not come so near the surface. I am inclined to 
think it is toward the back of the descending part of the arch; 
but wherever its exact locality may be, it evidently interfered 
with both arteries, veins, and nerves, which supply the arm, in- 
tercepting the pulse-wave and the nervous current, and causing 
anasarcous tumefaction from its obstruction to the return of blood 
by the veins. 

Local treatment was desirable, and leeches were applied several 
times beneath the clavicle. He would have been bled also ; but 
five days after admission he fortunately caught scarlet-fever from 
a neighboring patient, and it struck me that this might prove a 



THORACIC ANEURISM. 323 

substitute for venesection ; for it gave us a plea for keeping him a 
close prisoner in bed, and putting him on very low diet. This 
plan was the easier carried out from his being, like most civilized 
Africans, of a mild tractable disposition, and it has been pursued 
steadily up to the present time. On December 1, it is noted by 
the clinical clerk that he had recovered power over the arm, and 
that the pulses appeared nearly equal. He has continued the 
complete rest, and has taken prussic acid and digitalis. There 
is now^no difference to be detected between the radials, and he 
has regained complete use of the arm ; he describes himself as 
quite well enough to be an out-patient, and finds a bandage which 
he wears across the chest sufficient to relieve the occasional pains. 
There is a murmur still in the infra-clavicular region ; but all im- 
pediment to circulation occasioned by the aneurism has ceased. 

The treatment which has been adopted here is an exemplifi- 
cation of the principles which I have taught in the systematic 
lectures on the principles of medicine, and I must refer you to 
those lectures for an historical account of the adoption of this 
practice in the seventeenth century by Valsalva. It is a strict 
following up of that which nature adopts in all aneurisms that 
heal spontaneously. In them you find a fibrinous clot formed, 
and the sac shrunken up from lack of stream passing through it. 
Here we have tried to make the blood likewise form fibrinous 
clots, by bringing it into that fibrinous state which loss of blood, 
anaemia, and low diet induce; and we have tried to keep the 
blood-stream as calm as possible by rest in the horizontal posture. 

The pathology of aneurism shows it to us as a local deficiency 
of life in a hollow organ, a deficiency of vital elasticity, which 
has let this hollow organ yield to the continuous pressure of the 
blood-stream. Doubtless if we could at first have renewed this 
vital elasticity, such would have been the legitimate aim of treat- 
ment, and such would be the course pursued by a rational phy- 
sician. But here the mischief is already done, the vessel has 
dilated into an uncontractile sac and is beyond the reach of any 
of the powers of life. The object now must be to restore as much 
as possible the original area of the vessel, and to reinforce the 
weakened walls by an artificial clot; so that though we cannot 



324 THORACIC ANEURISM. 

have a complete artery, we may have as good a substitute for it 
as circumstances will allow. 

There was much in favor of this patient from the outset : the 
aneurism was in the descending aorta; there was no thrill; his 
general health was good; and he is an obedient quiet creature, 
very different from the ill-conditioned little woman last discussed. 
At all events he has done very well ; and I should urge upon you 
to make the carrying out of this principle of treatment the goal 
of your wishes in thoracic aneurism. You will find patients very 
often rebel, but do your best; and if you attain not success, you 
will at any rate deserve it. 

I like in general to bleed the patients affected with aneurisms 
from time to time, and should have employed that mode of treat- 
ment if this man had not had the scarlet-fever. A former patient 
of Dr. Sibson's, now an out-patient, testifies from his own ob- 
servation to the superiority of venesection over leeches in its 
•calmative influence over an aortic aneurism which he has long 
had, and on which he is very observant to the effect of remedies. 
But I have heard an opposite opinion given by patients. 

I said you will deserve success, and sometimes you will get it. 
I kept a stone-mason in this hospital under the bleeding and 
starving treatment for five weeks. He had come in with a pulsat- 
ing tumor and aneurismal whiz under the left scapula, with severe 
pain in the floating ribs, which some thought were being absorbed. 
At the end of the five weeks he rebelled, and our relation as phy- 
sician and patient was at an end ; but the pulsation had disap- 
peared, and the whiz was scarcely to be heard; and I had reason, 
therefore, to think the aneurism in a fair way to be cured. 

Even in cases where the treatment cannot be carried out a 
Voutrance, good may be done by an approach to it. In 1851, a 
lady was sent to me by a surgeon in the country, to consult me 
about increasing corpulence and dyspnoea. In investigating the 
cause of dyspnoea, I found a pulsation and an obscure whiz under 
the left clavicle, accompanied by deficiency of pulse in the left 
wrist. I was satisfied that there was aneurism either of the sub- 
clavian or of the aorta at the origin of that branch. But bleed- 
ing-was undesirable, because she was so fat. I have often told 



THORACIC ANEURISM. 325 

you how badly obese people bear bleeding. Moreover, she was 
sixty years of age. But, as she was a sensible woman, I managed 
to gain her confidence, and starved her for several weeks, giving 
her at the same time drachm doses of liquor potassae three times 
a day. The effect was a reduction of her corpulence, a diminu- 
tion of the pulsation in the tumor, and greater freedom of breath- 
ing. I did not see her from 1851 till 1856, when, being in Lon- 
don, she called to show herself, saying how well she was. The pulse 
in the radial artery had not returned; but there was no beating 
in the tumor, and only a sort, of roughness in the sound of the 
artery. She felt confident herself of the good effect of the starv- 
ing treatment. 

I have taken the opportunity of your having two patients 
together under your eye to bring the subject of aneurism before 
you, because of late the objections urged against venesection in 
excess and in improper cases have produced a fashion of decry- 
ing its use altogether, and especially in thoracic aneurism. Bleed- 
ing and starving, it is urged, induce debility and anaemia; that 
is to say, in physiological language, they lower the force of the 
heart, and they cause a comparative excess of fibrin over blood- 
disks in the blood. These are both steps toward the mode adopted 
in nature to effect a cure of aneurism, and, perhaps, of some 
other diseases also. So that, I contend, not merely is it the best 
mode, but the only honest mode of treating aneurism of the 
trunk-vessels ; because it is the only one we at present know con- 
sonant to reason and experience. 

{Clinical, St. Marys, February 20, 1863.) 

Thomas W., aged thirty-nine, a decorative painter, had always 
enjoyed robust health till the 4th of this month, when he was 
standing on a ladder graining a shop-front. Without any warn- 
ing or previous feeling of illness he suddenly lost his senses and 
fell down. On coming to himself after a few minutes he found 
he was not paralyzed in any part, but had severe pain in the 
side. This he attributed to the fall, and thought that he had 
broken a rib. No fracture of the bones however could be found, 



326 THORACIC ANEURISM. 

and the pain in the side appears to have been treated as for 
pleurisy caused by the injury, the most natural diagnosis under 
the circumstances. On his admission to the hospital on the 11th, 
a week after the accident, the whole of the left side of the chest 
was dull on percussion before and behind, and there was entire 
absence of breathing except in the two upper inches next the 
collar-bone, where it was bronchial, the sough of expiration 
being very prolonged. There was no pulsation or heart sounds 
perceptible in the cardiac region, the organ being pushed over 
to the right side beyond the median line. A blister was applied 
to the left side, and on the 14th the heart was much nearer to 
its natural place than before, and the breathing in the upper lobe 
of the left lung more normal. He said he had less difficulty in 
respiration, and no pain in the side. I still continued to hold 
the original diagnosis, and supposed the pleuritic fluid to be in 
course of absorption. 

He continued going on well till the night of the 15th, when 
he suddenly jumped up, exclaiming that he was dying, put his 
hand to his side, fell back deadly pale, and soon ceased to 
breathe. 

The post-mortem examination has explained the mystery. You 
see here in the descending portion of the thoracic aorta, just 
above the diaphragm, the sac of an aneurism large enough to 
hold a man's fist, out of the left side of which a smaller sac, about 
as big as a chestnut, protrudes toward the left pleura. And in 
this smaller sac there is a rent a quarter of an inch long, which 
allowed the blood to flow freely out into the cavity of the pleura, 
and to fill it up with between five and six pints of blood. The 
blood had so far separated into serum and coagulum that the fluid 
which first issued on opening the chest was about as clear as that 
which you find in a bleeding- cup carefully put by; it was hardly 
at all stained red. The heart was not at all injured by its dislo- 
cation, though lying entirely to the right of the cardiac region. 
The left lung was very little pervious to air, being sodden and 
inelastic in tissue. The pleura was quite natural, showing no 
signs of inflammatory action. 

I need hardly say that no suspicion of the true state of things 



THORACIC ANEURISM. 327 

crossed anybody's mind during the patient's life. The mode of 
death is so rare, that if an exactly similar case appeared to- 
morrow, while this one was fresh in my mind, I think I should 
make the diagnosis I did here, of a collection of pleuritic fluid 
from injury to the pleura or lung. Even during the autopsy a 
gentleman present, with a juvenile objection to being wrong in 
a diagnosis, upheld the idea of its having been originally a case 
of serous effusion, into which the aneurismal sac had burst at 
the time of death. Tempting as it is to prove one's self right after 
all, I was compelled to differ; for had such been really the case, 
the blood suddenly mixed with the previously collected fluid 
would have stained it all deeply, and not have been seen sepa- 
rated into serum and crassamentum, as it was, on opening the 
pleura. 

I feel sure that the aneurism first burst at the time of the 
man's accident. Then that the prone posture and the fainting 
allowed a fibrinous plug to stay further mischief for a time; and 
that the giving way of the plug was the immediate cause of 
death. 

This case shows how imperceptible and with how little injury 
to health may be the growth of a large aortic aneurism — even 
one extensive enough to have eroded the vertebral column, as 
this has done. The patient did not know what illness was till 
the rupture took place. And perhaps that was a consequence 
of the fall in a fainting fit. Do not let this discourage or terrify 
us with the fear of carrying, without being aware of it, such a 
dreadful inmate in our chest. Let us rather comfort ourselves 
with the assurance, that if it has wrought so little harm when 
not known of, it may be prevented from doing harm when it is 
known of, if prudence is used to avoid accidents. A clot inside 
this sac would have completely restored the form and functions 
of the aorta. 

Even with a rent a quarter of an inch long in it, you see it 
was not necessarily fatal. The patient lived nearly a fortnight, 
the blood first poured out was beginning to be absorbed, the 
heart was returning to its place, and the lung to its breathing. 
If we could have seen what was going on inside, there would 



328 THORACIC ANEURISM. 

have been nothing extravagant in the hope that a permanent 
stoppage of the hole might have taken place; though, of course, 
the risk of the fatal accident which has really happened would 
have been equally clear to us. 

(Clinical, St. Marys, December 12, 1863.) 

Albert D., a carpenter, aged thirty-three, enjoyed general good 
health till three- months ago, when he became an out-patient for a 
constant distressing cough and shortness of breath. This state 
of things became worse and worse, and he was sent to bed, under 
my care, November 11. It was then found that the pulse in the 
right wrist was very much smaller than in the left, an abnormal 
degree of pulsation was felt in the hollow above the collar-bone, 
and a characteristic whiz, as of an aneurism, could be heard 
where the pulsation was strongest. I believe all who examined 
him came to the same conclusion, that there was an aneurism of 
the arteria innominata, or at all events involving the arteria in- 
nominata, and pressing upon the trachea. The diagnosis was too 
clear to be of much interest. The lungs were very much con- 
gested, coarse and fine crepitations being heard in various parts, 
and the finer crepitations especially in the lower lobes, of which 
the right, on percussion beneath the scapula, was duller than the 
left. The patient was harassed by constant dyspnoea and fre- 
quent cough, especially at night, and had severe pain, sometimes 
spasmodically aggravated, in the neck behind the right collar- 
bone. There was copious muco-purulent expectoration. 

To relieve the afore-mentioned pain, general bleeding from 
the left arm was once resorted to, and several times leeches were 
applied above the clavicle. The patient said that the leeches 
gave the most relief; an assertion different from what I have 
heard made in other cases of aneurism of the trunk vessels, and 
I am sorry to say I cannot explain the discrepancies. 

Digitalis and lobelia were also administered internally, and 
blisters and mustard poultices were applied externally; but I 
cannot say that either gave any relief to the cough or dyspnoea ; 
and indeed a week before his death they were left off as ap- 



THORACIC ANEURISM. 329 

parently inefficient remedies. Morphia alone and the afore- 
mentioned leeches seemed of any advantage. 

A week ago he had an attack of haemoptysis; but that was 
arrested by leeches, and he went on without much change, vary- 
ing in his fortune from time to time, now better, now worse, till 
yesterday. In the morning he told the sister of the ward he 
thought he was really improved in health, and that he could lie 
down easier in bed. But after dinner he experienced great dif- 
ficulty in breathing, said he felt he was dying, sent for his wife 
and mother, and became livid and insensible almost before they 
arrived. To-day you are going to see the post-mortem examina- 
tion. 

[Extract from record of post-mortem Examination by Mr. 
Nayler, curator to St. Mary's Hospital Museum: "The aorta 
in its ascending and transverse portions was greatly dilated, and 
involved the origin of the innominata artery. Its coats felt also 
somewhat hard and brittle. In consequence of its increased size, 
the aorta rose much higher than natural in the chest, and ob- 
scured the root of the innominata. On laying open the trachea, 
its upper part was found to be healthy, but in its lower half the 
mucous membrane was much congested, and its rings flattened, 
and at this point they appeared to have undergone partial ab- 
sorption. The heart was soft and thin. The lungs were very 
full of blood, and at the back part were not universally crep- 
itant."] 

The cause of death doubtless was a sudden increase of the 
congestion of the lungs from the interference of the dilated ar- 
tery with the pneumogastric nerve, perhaps especially with the 
recurrent branch. Probably the only chance of relief for him 
would have been a recurrence of the haemoptysis which was of use 
a week ago. I should have practiced bleeding and leeching more 
assiduously, had not the weakly pulsation of the heart given a 
warning against it, and made one doubt if life would be pro- 
longed by that expedient, while complete renewal or cure was 
out of the question. 

Do not set down loss of blood as a mere destructive agency, 
pure and simple. The more perfect and accurately graduated 
22 



330 THORACIC ANEURISM. 

form of it exhibited in haemoptysis, and our rough imitations 
with lancets and leeches, by relieving the congested lungs of a 
burden that impedes their functions, cause more new blood to be 
made than heretofore, and so are an indirect renewal of life. 

You may observe that this man has had a considerable amount 
of digitalis, and that no beneficial result has been apparently 
produced by it. I must therefore say something justificatory of 
myself for administering it. My reason is, that digitalis seems 
to me to exert a special influence over involuntary muscular fiber, 
causing its contraction to be more firm and powerful ; and that 
it exerts this influence most especially when the muscular fiber 
is abnormally lax, or when it is degenerated. Cats killed during 
the action of digitalis were found by Dr. Handheld Jones, in ex- 
periments he made some years ago, to have the heart strongly 
contracted. In the human subject I have, ever since I have 
been physician to St. Mary's, hardly ever omitted to give digi- 
talis to cases of thin dilated heart, with irregular failing pulse ; 
and the general result you have often seen to be, that the pulse 
grows firm and regular. Digitalis acts also upon the involuntary 
fibers of the uterus, renewing their tone, bracing them up, and 
stopping the menorrhagia of relaxation. You have several times 
had an opportunity of seeing menorrhagia stayed in this way, 
and notably one case admitted under my care rather more than 
a fortnight ago, which I especially mention now, because other 
involuntary fibers than those of the uterus were influenced. 

Emily T., a quadroon nursery-maid, out of place from illness, 
aged seventeen, was admitted November 27, suffering from men- 
orrhagia, which had been almost constant for about three months. 
The quantity of blood lost was not large at any one time, but 
there was a continuous drain which had weakened her very much 
and rendered her very anaemic. Her mother, a tall and stout 
mulatto, stated that the disease was hereditary, she having her- 
self been laid up in the same way when a young woman. The 
girl's uterus comes down very low in the vagina, almost to the 
hymen, and the os uteri is soft, tumid, and painful. There is 
also pain on pressing the region of the ovaries. She stated in 
addition, and the statement was confirmed by her mother, that 



THORACIC ANEURISM. 331 

from childhood she had been afflicted with incontinence of urine, 
and never remembered to have passed a night without wetting 
her bed. Infusion of digitalis was prescribed, and the dose 
gradually increased up to two ounces every three hours. At this 
point it was left off, for nausea and faintness with loss of appetite 
were induced, and the menorrhagic discharge ceased. It has 
since returned once for a few hours, but was immediately checked 
by a resumption of the digitalis. So far the course of events 
was the usual and expected course ; but the next observed phe- 
nomenon is to me at least new; the patient states that the incon- 
tinence of urine has quite disappeared since the night before the 
arrest of the menorrhagia, that for the first time within her 
memory she has been able to hold her water during sleep, and 
now has not wetted her bed for ten nights. 

The beneficial action of digitalis over the sphincter of the 
bladder is of a piece with its action over the uterus, and is truly 
not surprising. I was not aware of it before, but shall certainly 
test it again, both in this girl in case of a return, and in other 
instances of that most unmanageable disease, incontinence of 
urine in the female. 

This digression is for the purpose of excusing my hope that 
digitalis might prove of use to the dilated and relaxed muscular 
fibers of arteries. The hope may be grounded on imperfect 
knowledge, and was disappointed in this instance; but it is not 
an utterly irrational one, not a mere excursion into the realms 
of empiricism. 



LECTURE XXV. 
DISEASE OF HEART. 

1st Part. Comparison of injury to life from the two sets of 
valves, severally — Deductions from autopsies — Case in point 
— Treatment calmative and restorative. Second case — Dis- 
eased mitral and aortic valves with dilated parietes — Treat- 
ment similar to last case, with certain additions. 

2d Part. Degree of importance to be attached to the different 
points ascertainable by ascultatory diagnosis — Consequences 
of valvular disease different in different classes of life — 
Cases in illustration of its effects in the upper classes as dis- 
tinguished from hospital patients — Causes of difference — 
Treatment of patients with disorganized valves — Avoidance 
of dangers — Iron — Chloride of sodium — Hydrochloric acid 
— Abuse of alcohol — Danger of rupture of valves — Case — 
Angina pectoris— Pathology of dilatation — Explanations to 
patients — All diseases of heart to be viewed practically as one. 

{Clinical, St. Marys, December 20, 1861.) 

In speaking of diseases of the cardiac valves I practically in- 
tend what is said to apply only to those of the left side of the 
heart ; for the tricuspid and pulmonary are seldom affected alone 
with such severity ^as to produce either symptoms during life, or 
lesions recognizable after death; so that physicians know very 
little about them. It is the mitral and aortic valves whose al- 
terations we are best able to recognize by physical signs, and 
whose defects cause injury to the muscular walls of the heart. 
They are a source of anxiety to us in our daily duty, whereas 
the others are rather a matter of curiosity. 



DISEASE OF HEART. 333 

Comparing the different valvular lesions of the left heart, with 
regard to the injury they inflict, and the consequent propor- 
tionate goodness or badness of the prognosis to be formed, I find 
that the worst cases, that is, the most liable to have serious con- 
sequences, are those in which both the aortic and mitral valves 
are. simultaneously imperfect; the next worse are those in which 
the aortic have suffered ; and the most favorable are those where 
the mitral alone are inefficient. 

Thus I find that in 115 cases recorded in the " post-mortem 
book " at St. George's Hospital from 1840 to 1850, where disease 
of one set of valves was accompanied by alteration in the cardiac 
walls, the aortic valves alone were diseased in 64, the mitral 
valves alone in 51. And in the former case also the alteration 
had assumed a more marked character; for in cases where the 
aortic valves alone were diseased, the size of the cavities was 
disproportionally large in comparison with the enlarged walls in 
36; whereas, when the mitral valves alone were diseased, the 
disproportionate enlargement occurred in only 18. And this 
difference, it is to be observed, is not dependent on the greater 
frequency of lesions of the aortic valves alone, for in point of 
fact they are not more frequent. Thus in hearts whose walls 
were still normal, there was more or less lesion of the mitral 
valve in 34, of the aortic in 30. 

The powerful influence of the double lesion (i.e. of both valves 
at once) is shown by its being found with healthy heart-walls in 
only 6. 

Now this diseased state of the heart's walls is so very much 
the most important, and so very much the most frequent of the 
evil consequences of disorganized valves, that practically speak- 
ing it may be taken to represent the whole of those consequences. 
All our calculations of prognosis in cases of valvular injury need 
have reference to it alone. 

I have been hitherto quoting from my systematic lectures on 
the practice of medicine, apropos of a prognosis I have given of 
a case now under your eyes, and which I have selected as one 
promising enough to use as an illustration of treatment. 

A. J., aged thirteen, had rheumatic fever three years ago at 



334 DISEASE OF HEART. 

Brighton, of which illness she has not much recollection, but she 
shows marks on the cardiac region of leeches, probably applied 
at that time for inflammation of the heart. She has since then 
always suffered from palpitation on the slightest exertion, or on 
any emotion ; and she has dyspnoea on attempting to go up stairs 
or up hill, or to walk above her usual pace. She had an attack 
of spitting of blood eighteen months ago, but otherwise her health 
has been good. Her complexion and appearance fully bear out 
this statement; she is fresh-colored, muscular, bright-eyed, and 
plump; her mind is active and intelligent, and though the mam- 
mae are infantile and the catamenia have not appeared, she has 
the air and appearance of a girl two years older than her real 
age. I may remark in passing that such a backward develop- 
ment of the reproductive organs as you here see is a very com- 
mon effect of cardiac disease in both sexes. The growth of the 
other organs or functions, mental or bodily, does not seem to be 
retarded. 

The palpitations have been lately rather more troublesome 
than usual, and on examination of the chest they are explained 
by a vibrating tremor sensible to the finger at the apex of the 
heart, and at the same point a very loud systolic murmur. The 
second sound is loud and sharp. The interval is clear. The 
systolic murmur is heard only very indistinctly at the base of the 
heart. On admission the pulse and heart-stroke were uneven in 
strength, but have by rest in bed become nearly natural. 

On percussion the dullness of the cardiac region does not 
appear to extend beyond the breadth and height which is usual 
in the normal state. 

This girl appears to labor under lesion of the mitral with 
healthy aortic valve, one of the varieties of cardiac injury the 
least likely to cause enlargement, and therefore the least injuri- 
ous of any ; and since I cannot find that the heart is as yet en- 
larged, let us give her the benefit of the doubt, and hope that it 
may not become so. 

In the treatment, the first object is to restore regularity and 
calmness to the affected organ. With that view she has been 
kept lying down for a week ; she has had once two leeches and 



DISEASE OF HEART. 335 

once one leech applied beneath the left breast, and has taken 
five minims of tincture of digitalis three times a day. This has 
been so far effectual, and will be continued only a short time 
longer. 

The next object is to keep the blood in as rich and nutritious 
a state as possible. The child has a critical period of her life to 
go through sooner or later, the time of puberty, when there is a 
call upon all the powers of growth. If she gets anaemic then, 
the heart will but too surely enlarge by dilatation. I have begun 
therefore giving her iron from the first, and shall urge its con- 
tinuance as long as I can keep sight of her. 

The richness of the blood, instead of increasing the chance of 
haemoptysis, as you might have imagined, diminishes it. Thin 
watery blood easier oozes out ; and besides, the more nutritive 
the circulating fluids, the more active is the heart, the better it 
empties itself, and the less is the blood kept back in the lungs. 

Another case in the same ward is not quite such a hopeful 
one. Mary K., aged twenty- two, single, has been here since 
November 25. She says that she has had rheumatic fever once 
this time seven years. She had no pain in the chest then, and 
perfectly recovered, remaining well till an attack of what she 
calls " bronchitis," three years ago. After this again she was 
quite well till two years since, when she began to suffer from 
severe pain in the cardiac region, and had frequent colds. She 
also frequently had bleeding at the nose, and spitting of blood, 
even when keeping quiet, and when she moved about experienced 
much dyspnoea and palpitation of the heart. She however con- 
tinued in service, and did her work. Six weeks before admission 
she observed that she got blue in the face, and suffered more 
than usual from dyspnoea, so that three weeks before she was 
obliged to give up work. 

• When you first saw her she was very blue in the face, and 
could hardly get her breath ; she was spitting blood, and there 
were loud sibilant and crepitant rales all over the lungs without 
any localized dullness on percussion in the pulmonary regions. 
The pulse was very irregular and intermittent. The cardiac 
region was dull on percussion up to the interval above the third 



336 DISEASE OF HEARTr 

rib, and as far as the sternum toward the right side. The 
second sound of the heart was scarcely to he heard at all, but 
was replaced by no murmur. There was a loud systolic murmur 
loudest at the apex, and followed by a peculiar chirping sound, 
rather anterior to the time of the second sound. The intervals 
were imperfectly marked. 

In Mary K. there is probably regurgitation through both 
aortic and mitral valves. What she has suffered from is ob- 
struction to the passage of blood through the lungs, and conse- 
quent non-aeration and venosity. She had some haemoptysis 
which gave relief, so I took the hint and cupped her, and put on 
some leeches several times, which ha\*e also given relief. The 
irregularity and excitability of the pulse have been successfully 
treated by digitalis. 

The venosity of the blood is in great danger of being succeeded 
by ansemia, especially as her appetite it very deficient. The 
heart is already enlarged, and I fear it is improbable that she 
will ever be able to get her own living again ; still I think it 
right to give her iron, and purpose to continue it as long as pos- 
sible, that at all events she may obtain all the advantage she is 
capable of receiving. The most unhappy event for her would be 
degeneration of the muscular walls of the affected viscus, so that 
they should fail from debility duly to circulate its contents ; and 
I believe the best chance of avoiding this degeneration lies in 
keeping up the supply of a really nutritious blood. 

You may observe that the digitalis was left off several times. 
This was not on account of its failing in its objeet of calming 
and reducing to regularity the irregular heart, for that it effects 
well ; but because, when given in larger doses than five minims 
of the tincture, it produced nausea and prevented her taking her 
meals. Now the physic we order on the diet card is at least 
equally important with that on the medicine card, and you must 
be careful where you want to renew life not to diminish the 
means of that renewal. The production of nausea and loss of 
appetite would do more harm than any action of the drug could 
do good. 



DISEASE OF HEART. 337 

(Clinical, St. Marys, December 6, 1861, with additions in 1862.) 

There are always in our wards a few chronically diseased 
hearts, and I very seldom walk round without calling your at- 
tention to one or two as studies of diagnosis. 

I notice that when you begin the physical examination of the 
patient whom you know to have a cardiac complaint, you search 
first and foremost for endocardial murmurs, and then you often 
rest from your labor and say what you have found. You seem 
to consider that sign as the most essential part of the diagnosis. 
You are partly right and partly wrong. 

This knowledge doubles the value of other future observations 
about the heart, but standing alone it is of less importance than 
any of them. While then I willingly receive this report first, I 
always beg you to go on without delay to further observations. 

The importance of the existence or non-existence of valvular 
disease lies not in the injury it inflicts itself, as in the likelihood 
of the induction of the other lesions of the heart. If the mus- 
cular structure remains healthy, injured valves do not appear 
capable of causing death. But very surely are they fatal when 
they are followed by dilatation or thickening or degeneration of 
the cardiac walls, with their sad train of dropsies, apoplexy, 
pulmonary haemorrhage, &c. 

In the 2161 post-mortem examinations at St. George's Hos- 
pital in ten years, the cardiac valves were diseased without the 
walls of the heart being affected 113 times ; but in every case 
there were other lesions amply sufficient to account for death 
quite independent of the valves, such as accidents, surgical com- 
plaints, cancer, low fever, &c. In one alone, where anasarca 
from granular kidneys was the immediate cause of death, could 
any symptom be debited to diseased valves with healthy heart, 
and that symptom was pulmonary haemorrhage.* 

In the classes of people represented by hospital patients, the 
probability that valvular disease will be followed by its unhappy 
consequences is very great. When a patient thus affected leaves 

* " Decennium Pathologicum," chap, x, sect. i. 



338 DISEASE OF HEARt. 

the wards, you may expect to see him again shortly, and on each 
fresh admission with a more severe complaint. Hence the more 
attentive students you are the worst prognosis do you justifiably 
form. But you must not apply the same rule to the different 
grade of society among whom you hope your private practice 
will lie. With persons in easy circumstances valvular lesions 
exist for years and years, perhaps through the greater part of a 
long life, and not only not prove fatal, but may fail even to 
cause symptoms bad enough to make them consult a medical 
practitioner. 

To prove to you this fact, I will quote from my private notes, 
some cases of persons in easy circumstances in whom the stetho- 
scope or the history, or both, gave every indication of injury to 
the valves of long standing, but in whom no inconvenience suffi- 
cient to be called illness by themselves has followed. 

Defective valves of 57 years standing. — Col. R. S. at eight 
years old had a bad attack of rheumatic fever, which laid him 
up for eleven months, and from which his heart has never wholly 
recovered. At sixty-five years of age he had a very loud murmur 
with the first sound. The year before he had had an attack of 
inflammation (congestion?) of the lungs, which had left a con- 
siderable portion of the pulmonary tissue impervious, for his vital 
capacity tested by the spirometer was only 150 cubic inches, his 
height being 5 feet 10J inches. 

Defective valves of 50 years' standing. — Archdeacon B. at six 
years of age had an attack of inflammation of the heart, and 
since that time has been subject to irregular action of the organ, 
often followed by fainting fits. He has for some years lived 
more generously than he used to do, and suffers much less in- 
convenience. The action of the heart is irregular and uneven, 
and there is a murmur with the first sound. He is now fifty-six, 
well, and moderately active. (Dec. 1861.) 

Defective valves of 44 years' standing. — C. B. at twenty-eight 
had rheumatic fever from sleeping in a damp bed. At sixty- 
three years old (in 1852) he had a marked systolic murmur at 
the apex of the heart, but considered himself quite well, and is 
alive now (1861) when he must have long passed his threescore 
years and ten. 



DISEASE OF HEART. 339 

Defective valves of 27 years' standing. — T. H. Gr. at six years 
old had rheumatic fever. Since then he has had no illness of 
any kind. In June, 1860, when he was thirty-two, I detected a 
loud whizzing murmur with the first sound; in July, 1861, the 
same murmur remained. He is alive and I believe well now. 
(Dec. 1861.) 

Defective valves of about 21 years' standing. — C. S., aged 
thirty-six, in 1855 had a low blowing mitral murmur. He used 
to have severe palpitations when an under-graduate at Cam- 
bridge; he has enjoyed average health since, with the exception 
of what he calls "colds," that is, a feeling of general malaise, 
for which he takes tonics, and is always better for the practice. 
He is alive and well now in 1862. 

Defective valves of lb years' standing. — E. G. in 1846 had in- 
flammation of the chest accompanied by severe pain in the heart. 
I saw him first in June, 1848, when there was a loud musical 
murmur with the first sound. In December, 1848, and in Janu- 
ary, 1850, the same murmur remained. He is still alive, aged 
seventy-two. 

Defective valves of at least 11 years' standing. — R. H., who 
in 1861 was still alive and forty-two years of age, had in 1850 
a blowing systolic mitral murmur. 

Defective valves of at least 7 years' standing. — R. A. A., who 
in 1862 is still alive, aged fifty-three, had a blowing systolic 
murmur when I saw him in 1854. He is a robust, muscular man, 
in the habit when young of pulling in boat races, to which he 
attributes the palpitations he now occasionally suffers from. 

Defective valves of 7 years' standing. — T. J., aged twenty- 
three in 1854, had undergone scarlatina at sixteen years old and 
never any other illness. I could hear a blowing systolic murmur 
at the apex of the heart, and he had pain in the cardiac region 
after exertion, but was not otherwise ill. His subsequent history 
is unknown to me. 

Defective valves of 7 years' standing. — D. F., aged twenty- 
nine in 1852, also had scarlatina at twenty-two years of age, 
accompanied by pain in the heart and followed by palpitations 
of six weeks' duration. There was with some beats a systolic 



340 DISEASE OF HEART. 

murmur loudest at the apex at that period, which was seven 
years after the reported cardiac affection. His subsequent his- 
tory is unknown to me. 

[Defective valve of 7 years standing. — Miss S. had rheumatic 
fever from sleeping in a damp bed, accompanied by pain in the 
cardiac region, in 1856, when she was twenty-three years old. 
There is a distinct very localized systolic murmur at the level of 
the aortic valves. She has attacks of angina pectoris from ex- 
posure to cold, but with care is able to live like other people. 
Between April, 1862, and July, 1863, she had lost no ground, 
and had only two slight attacks of angina pectoris.] 

Defective valves of at least 5 years' 1 standing. — F. J., aged 
thirty in 1856,. had then an irregular pulse and a systolic mur- 
mur, without any dyspnoea or general symptoms arising from the 
imperfection of the heart. He is alive now. (Dec. 1862.) 

Defective valves of 18 months' standing. — A. D., aged forty- 
three in 1850, had had rheumatic fever eighteen months previ- 
ously. The heart's action was irregular and there was a systolic 
murmur, but no general symptoms at all referrible to cardiac dis- 
ease, nor any suspicion that cardiac disease existed. His subse- 
quent history is unknown to me. 

Defective valves of a years standing. — W. H. C, aged thirty- 
one in 1850, had had rheumatic fever a year before, with inflam- 
mation of the heart, but considered that he had quite recovered, 
and he really seemed to have done so ; for his vital capacity was 
220 cubic inches, his height being 5 feet 9 inches, so that there 
was no pulmonary obstruction. There was a systolic murmur, 
loudest at the level of the aortic valves. His subsequent history 
is unknown to me. 

Defective valves of unknown duration, but at the date of 
examination without any deleterious effect on the general health. — 
J. P., aged thirty in 1854, had an intermittent pulse with a 
systolic murmur loudest at the base and middle of the heart. 
Unusual exposure affected his chest so as to lay him up with 
cough, but his general health was good. Subsequent history 
unknown to me. 

G. P., aged twenty-six in 1856, had a very irregular, unequal, 



DISEASE OF HEART. 341 

and intermittent pulse, accompanied by a systolic murmur. He 
never suffered from palpitation, cough, or any illness at all. Sub- 
sequent history unknown to me. 

F. D., aged forty-nine in 1857, had a sawing systolic murmur, 
but never had any illness or inconvenience referrible to the heart. 
Subsequent history unknown to me. 

J. B., aged forty-eight in 1856, had an intermittent pulse and 
a blowing murmur with first sound most distinct at the base of 
heart. He never suffered from palpitations. Subsequent history 
unknown to me. 

Irregular pulse of long standing without date. — Lord , 

aged seventy-four in 1862, and alive now, with a soft systolic 
murmur to be heard at the apex of the heart, has a distinct recol- 
lection of having an irregular pulse as long as he can remember 
anything. And other old people have told me the same, though 
I have not kept a note of their cases. 

Injury to heart from rheumatic fever of '10 yiars standing. — 
T. A. 0., aged fifty-one in 1855, had had rheumatic fever ten 
years previously, and since then frequent "faintingfits" and 
palpitations. The action of the heart is jarring, and there is 
extended dullness on percussion, but no evidence of valvular dis- 
ease. He does not get worse. 

You know very well that cases like these are not to be met 
with in hospital practice or among the paupers in a workhouse. 
Wherein lies the difference ? It is discoverable generally from 
the histories which these poor people tell of the final breakdown. 
The tale usually runs, "I was pretty well, or only a little short- 
winded, till I was thrown out of work and had to live low : then 
my heart got to beat worse, and my feet swelled." Or, "I could 
always earn my living till I was overworked last summer," or, 
"till I caught a bad cold last winter," or, "till I had sit up with 
my mother who died," and so on. And from this breakdown 
they never get quite up again* they never regain lost ground. 
In short, you will see that injured valves are slow to lead to 
further cardiac lesion in the well-nourished, and quick to lead 
to further lesion in the ill-nourished; and that the motive cause 
of their evil effects is anaemia, exhaustion, debility. 



342 DISEASE OF HEART. 

Do not look upon this disadvantage of the poor in respect of 
cardiac disease as merely an universal rule in all diseases. In 
a good many cases the poor recover easier than the wealthy, and 
the good prognosis which you have habitually attached to certain 
morbid states in hospital practice will not be justified in private. 
Continued fever, to wit, is less fatal in the lower classes, although 
more common; consumption is less frequently "galloping;" it 
is more chronic, and more rapidly benefited in their case ; again, 
anaemia is more often found dependent on removable causes, and 
therefore quicker cured in cottages than in palaces. 

The peculiarly fatal nature of valvular disease of the heart 
among those who live by bodily labor arises from the fact just 
mentioned of lost ground being never recovered from. The heart 
is (physiologically speaking) a single organ with the single me- 
chanical function of forwarding the blood, and consisting of a 
number of unique parts mutually dependent on one another. If 
the left ventricular valves are injured, the right cannot take their 
office, nor the aortic replace the pulmonary. It is a chain, pro- 
verbially never stronger than its weakest link. Therefore no 
relief can be given to a failing part by another part taking its 
duty; no rest for the purposes of recovery can be taken. The 
designer of our frames has been here peculiarly sparing of reserve 
function. Such is not the case in other organs; if one kidney is 
destroyed, the other supplies its place and as much urea is ex- 
creted as before : large portions of lung may be impervious from 
tubercle, yet the blood be aerated normally by the remainder, 
and the patient recover of consumption. But in the heart each 
successive little injury can never be compensated for, and is added 
in turn to the previous list. The wealthier classes can avoid all 
the many circumstances which produce these successive little in- 
juries — cold, want of food, overexertion, mental worry; and so 
under good advice can keep their imperfect valves from getting 
worse; but those who depend upon daily toil for daily bread run 
the risk and suffer the unhappy results. 

I said early in the lecture that I did not blame you for begin- 
ning your examination with listening for cardiac murmurs, but I 
do blame you very much if you stop there. The evil import of 



DISEASE OF PEART. 343 

valvular injury lies in its probable consequence, namely, enlarge- 
ment of the muscular walls; and it makes all the difference in 
the world to you and to the patient to ascertain if this already 
exists. Percussion and palpitation are a much more necessary 
part of the examination than mere listening with a stethoscope. 
If the heart is dilated or thickened, or dilated and thickened, 
your ascertaining the fact makes all the difference in the world 
to your prognosis, and to the hopes which you have that your 
treatment may be successful. 

It is obvious that in the treatment of the disorganized valves 
themselves, restorative medicine in the strictest sense must be 
quite at fault. The renewal of the destroyed tissues is impossi- 
ble, and equally so is any compensation for the arrested function. 
But indirectly it is almost as effective in prolonging life, as if it 
could put in a new valve, or make another muscle do duty for 
the resting ventricle. It may repair those reparable conditions 
which are so injurious, and which by bringing on enlargement 
constitute the real danger in cardiac cases. In this, as in all dis- 
eases, try and cure what is curable and trouble yourselves as little 
as possible about by-gone injuries. 

Learn from the^ histories you hear in the wards what are the 
external causes which have brought on the first affection of the 
health, and you will thus learn the perils which your patient with 
valvular injury has to fear. These are, placed roughly in the 
order of prominence — 

fresh .attacks of rheumatism ; 

insufficient food ; 

mental anxiety; 

drinking; ^ producing anemia. 

overwork ; j 

temporary violent exertions. 

The first danger is to be avoided by warm clothing, dry air, 
especially in the sleeping room, and a residence in such a climate 
as does not naturally induce rheumatism. As a rule, high ground 
is to be preferred to low, and an inland to a seaside or island 
abode. A town life, as being more healthily sedentary and 
avoiding changes of temperature, is rather to be chosen than 
rural occupations. 



344 DISEASE OF HEART. 

During the attacks, if unfortunately they come on, you cannot 
do better than adopt the full treatment of rheumatic fever, namely, 
the greatest possible quantity of potash and sufficient doses of 
opium, as more largely set forth in my lecture on rheumatic 
fever. And you must leech or cup the cardiac region, if there 
is any pain there indicating the probable presence of fresh en- 
docarditis or pericarditis. 

But do not let the license you give yourself of local blood- 
letting to a moderate extent for the relief of an acute condition, 
which you fear may aggravate existing evils, — let not, I say, 
this license lead to your adopting the old "heroic" practice of 
thinking to cure established valvular injuries by continuous 
bleeding, like our forefathers Albertini and Valsalva. They 
fell into the mistake thus: they first supposed every enlarged 
part was overnourished, «or hypertrophied ; then they thought 
that the best thing to prevent its overnourishment was to under- 
nourish it; and then finding that bleeding in moderation some- 
times lightened a few symptoms, they determined that it did so 
by undernourishing the heart, and that of course the more the 
patient got of it the better. Under the idea of producing its full 
influence, they bled frequently in small quantities — the most 
effectual way of accomplishing the end they had in view, the 
impoverishment of the blood. With bleeding for such an end it 
was strictly reasonable to join starvation, as certainly the most 
direct way of diminishing nutrition. What the results would be 
of thus deliberately inducing anaemia we can easily guess, for 
daily experience shows that in none do the hearts so rapidly be- 
come enlarged, and on none does that enlargement have more 
baneful effects than on those people who are subjected to all or 
any of the causes of anaemia which I have named. Had the 
Sangrado treatment really been in vogue now in England, I 
should have certainly ranked it in the first class of the origins 
of disease in patients with lesed valves. 

I have spoken of the poor as without doubt the most exposed 
to the effects of those agencies which produce or aggravate val- 
vular lesion ; but the rich are by no means exempt, and often 
require the protection of sound medical advice. Even "insuffi- 



DISEASE OF HEART. 345 

cient food" is not an unknown cause of illness among them; the 
power to buy it does not always imply the power to eat it. They 
not uncommonly become anaemic from loss of vigor in the digest- 
ive organs. To counteract the risk of this anaemia I usually 
recommend that persons with affected valves should, three or four 
times a year, take a fortnight's course of iron under the eye of 
their ordinary medical man, whose watchfulness is needed to 
prevent excess. The insoluble forms of the metal, such as the 
sesquioxide, or the finely pulverized metallic iron made by French 
chemists, or the mistura ferri composita, are the fittest for the 
purpose. Chlorine also in the form of hydrochloric acid baths 
is a tonic not contraindicated by any circumstances in this case, 
and is a good accompaniment to the iron. The habitual use of 
a large quantity of chloride of sodium with food is another way 
of guarding against anaemia, which can readily be adopted by the 
patient. 

When there is reason to fear that dilatation has already begun, 
I often join with the iron small doses (from 50-th to y^th of a 
grain) of strychnine. If the pulse intermits, this remedy some- 
times exerts its tonic power over muscular fiber by restoring 
regularity of beat, and thus gives you the satisfaction of feeling 
the good you do with it. When there is much palpitation on 
occasion of slight nervous excitement, especially if that is joined 
with unevenness and intermittence of pulse, a few small doses of 
digitalis are useful. Strange it is that this drug, which makes a 
healthy heart first intermit and then stop altogether, should bring 
back to order the organ- when it is weak and beating irregularly ! 
We can only account for the seeming anomaly by supposing it 
to act as an anaesthetic upon the cardiac nerves, withdrawing 
them from normal and needful stimulation in the first case, and 
from abnormal and hurtful stimulation in the second. The worst 
aspect of digitalis is, that its benumbing influence extends not to 
the heart alone, where it is wanted, but to the whole tract of the 
pneumogastric nerve; it reduces the appetite and produces 
nausea; so I pray you to be cautious and not to continue it 
longer than necessary. 

While you bid your patients live generously, you must take 
23 



846 DISEASE OF HEART? 

care to disabuse them of the notion that the advice includes ex- 
cess in alcohol. Alcohol is really the most ungenerous diet that 
there is. It impoverishes the blood, and there is no surer road 
to that degeneration of the muscular fiber which is so much to be 
feared. And in heart disease it is more especially hurtful, by 
quickening the beat, causing capillary congestion and irregular 
circulation, and thus mechanically inducing dilatation of the 
cavities. Let the alcoholic drink be limited to that quantity 
which increases the appetite, and fills but does not hasten the 
pulse. In a great many instances this quantity may be very 
shortly written down — 0. 

To mental anxieties perhaps their social relations expose the 
rich quite as much as the poor, and their education makes them 
more sensitive. Both joys and sorrows affect them more deeply, 
and instead of balancing one another do equal harm. Happiness 
is as hurtful as misery. For example, I have a patient whose 
first attack of dilatation arose from grief at his first wife's death, 
and his second during the honeymoon of her successor. But 
alas ! ungrateful discontented man seldom lets the blessings he 
is daily receiving affect his emotions so deeply as his occasional 
misfortunes. 

By overwork as a cause of anaemia, I mean too long-continued 
wearying toil either intellectual or boplily. I would have you 
distinguish from it short extraordinary exertions, to which we 
can sometimes, though not very commonly, trace injury of the 
valves. 

Now and then a case occurs showing the possibility of a, valve 
being ruptured by its own forced action. Thus I remember 
seeing one of Tattersall's stablemen under Dr. Nairne's care at 
St. George's Hospital, who distinctly traced his first cardiac 
symptoms to a sudden pang which he felt, when running a fast 
horse down the yard a year before. After death two of the 
pouches of the aortic valve were found torn, and from the re- 
gurgitation thus arising the ventricles had become enormously 
dilated during the year that he had lived. But the torn portions 
were not of normal structure ; the tissue was thickened and 
opaque, and therefore wanting in elasticity of power of resistance. 



DISEASE OF HEART. 347 

And I believe this always is found to be the case in valves 
ruptured by violent strains ; I am not aware of any instance of 
healthy valves having been found broken. 

Where the tissue has become bony and brittle, rupture is more 
common ; but then of course it will have been preceded by a long 
course of. ill health, for such an advanced lesion as ossification 
could not exist without seriously incommoding the individual. 
You will not be long without seeing in the dead body the cords 
of a mitral valve thus broken, rather from the quantity of lesion 
than from any external strain or violence. 

More common still are cases that you see during life of sudden 
pangs from exertion — such as race-rowing, jumping, fighting, — 
sudden pangs followed by increased palpitation, and other signs 
of aggravated enlargement of the heart. Yet the aggravation 
is not such as must surely accompany a broken valve, nor is the 
path to death so straight as it was in the case which I have re- 
lated to you. Moreover, in some instances where an autopsy 
reveals that the valves are whole, you had previously heard a 
history of such pangs, and sometimes had seen them in the 
wards. What is going on in the heart during these fits of angina 
pectoris no one precisely knows, but it seems to me very probable 
that its state is one of temporary dilatation. The pain has the 
same tearing and paroxysmal character that you find accompany- 
ing the distention of hollow fibrous organs usually insensitive, 
such as the stomach, the colon, the bladder.* And the con- 
sequences too are similar as well as the pain ; that is to say, like 
the bladder or the stomach, the heart may completely recover 
in one case; or in a second, it may be completely paralyzed and 
cause death ; in a third, it may remain partially powerless and 
dilated. As in the bladder, so in the heart, any one of these 
results may follow. 

Having said so much about the nature of injury by sudden 
strain, it is needless to remark that it is to be avoided by all the 

* The pain is of the same nature as that felt in overstrained tendons, or mus- 
cles wearied out by sustained efforts ; it appears associated with the stretching 
of usually insensitive fibers, and is sometimes the most dreadful agony the body 
can bear, as the inventors of racks and other instruments of torture well know. 



348 DISEASE OF HEART'. 

expedients that lie in the patient's power ; and perhaps the best 
way of strongly impressing upon him (if he is a sensible man) 
the importance of your advice, is to explain, that is put into plain 
words, the pathology of the case. I cannot agree with those 
who would make a mystery of our science. I am sure that we are 
never called upon to pervert the truth, seldom even to be pas- 
sively reticent, and that the most thorough openness is always 
the best policy. To this end a complete explanation is generally 
necessary. The patient must be told how erroneous are the 
vulgar notions derived from popular fiction about the extreme 
deadliness of organic disease ; the true facts of the case must be 
stripped of their picturesque hangings, and he must be led to 
look upon his condition with the same business-like reckoning of 
results as a physician. Unless this is done, your half truth will 
act as a lie. 

I should strongly advise you to get a habit of giving these 
clinical lecturettes in clear untechnical words. Let your pa- 
thology shape itself within your own minds in such language as 
all educated persons can enter into ; and not only will you -be 
able to explain matters more easily to your patient, but you will 
understand them better yourself. For this last statement " ex- 
perto crede." 

In practical lectures it is always wisest to take chronic diseases 
of the heart as one individual subject, for this is the way in 
which you have to think of them at the bedside. You should 
not treat patients with spoilt valves on one principle, those with 
dilated ventricles on another, those with thickened ventricles on 
a third ; but, as I have tried to make you think, each and all with 
a reference to the same function impeded in the same manner. 
Division leads to unnecessary repetition, and you may observe 
that I am careful to avoid it both in the way in which I class the 
patients in the wards for instruction, and in the extracts I make 
from case-books for the lecture-room. I do this with a design of 
impressing upon you what I consider the main points in the 
management of diseased hearts, viz. : 

1. The importance of valvular lesions consists in their liability 
to cause enlargement of the heart. 



DISEASE OF HEART. 349 

2. In auscultation we should strive more to find out the state 
of the heart-walls than of the valves. 

3. The danger of enlargement is greatest where the muscular 
fiber is weakest. 

4. The muscular fiber is weakest where the blood is most 
anaemic. 

5. The principal object therefore of treatment is to avoid 
anaemia. 



(Clinical, St. Marys, January 30, 1863.) 

Eliza M., an unmarried woman, aged twenty-six, has been in 
the hospital four times during the last three years with attacks 
of haemoptysis and dyspnoea, arising from valvular disease of the 
heart. She was last admitted January 16, with dyspnoea ac- 
companied by excessive lividness of the face. She was soon 
relieved by the recumbent posture and half a dozen leeches to 
the cardiac region. My reason for mentioning the case to-day 
is to draw your attention to the dyspeptic symptoms which seem 
dependent upon the disease of the heart. On admission she said 
that she vomited up all her food, and although she only did that 
once after coming into the hospital, still she suffered from con- 
stant nausea after eating, and tympanitic distention of the 
intestines. I have often found this form of indigestion in cases 
of heart affection. There is nausea, vomiting, sometimes a great 
collection of mucus in the stomach, and intestinal flatulence. I 
attribute the nausea and vomiting partly to the constant jar 
communicated to the walls of the stomach by the palpitating 
heart, and which acts somewhat as the rocking of a ship produces 
sea-sickness. Partly also I think it may be due to the general 
venous congestion which I have no doubt exists equally in the 
mucous membrane and in the external skin. The flatus in the 
digestive canal I think arises from the deficiency of absorption 
produced by congestion of the portal system. 

You must not look upon wind as a purely abnormal denizen of 
the alimentary canal. It would be a very abnormal state of 
things indeed if there were none found there. The greater part 



350 DISEASE OF HEART* 

of it is carbonic acid and atmospheric air derived from the food. 
But in health its quantity is limited and kept from inconvenient 
excess by its continuous passage by endosmosis into the portal 
and venous blood. Now it is a familiar law of osmosis that the 
ratio of the rapidity of its current bears a direct relation to the 
motion of the fluid toward which it sets. Obviously, then, 
obstructions to the circulation, by diminishing the quickness of 
the moving blood must impede absorption, and so allow the flatus 
to accumulate. It must be viewed as a collection not as an 
effusion. 

As regards remedies, I have found hydrocyanic acid have a 
beneficial effect. And in this case especially to give it is to ac- 
complish two indicata with the same agent ; for by its general 
action upon the pneumogastric nerve it alleviates the dyspnoea, 
at the same time that it deadens the oversensibility of the gastric 
plexus in special. 



LECTURE XXVI. 
PURPURA. 

Descriptive definition of purpura — Case 1. Young man affected 
with fatal haemorrhage and purpura without previous disease 
— Case 2. Menorrhagia and purpura in a girl otherwise 
healthy — Case 3. Purpura in a fatal case of diseased heart 
and kidneys — Pathology of purpura — Its connection with 
lesions of the circulating system — Its treatment based on its 
pathology — Cautions respecting the administration of digi- 
talis — Case 4. Purpura fatal by hemorrhage into the 
brain. 

(Clinical, St. Marys, February 6, 1864.) 

I wish to call your attention to-day to three examples of pur- 
pura under my care this week, which illustrate the phenomenon 
under several different aspects. 

Purpura, or "the purples," consists of a diseased state of the 
capillaries, which causes them to rupture idiopathically or of 
their own accord, just as they would do in consequence of local 
violence. On soft, or loosely constructed surfaces, such as 
mucous membranes, the escaped blood flows away in a fluid 
state; where a tougher structure prevents this escape, as in the 
external skin for example, it forms purplish black spots of 
rounded shape and various sizes ; in parenchymatous or semi- 
parenchymatous tissues, such as the brain or lungs, it may col- 
lect into masses which lacerate their substance and obstruct 
their functions. 

Case 1. John K., a laborer, aged thirty-five, previously quite 
well, was taken ill at tea-time on January 29, with bleeding 



352 PURPURA. 

from the mouth. This haemorrhage rapidly increased and be- 
came very profuse ; so that by the evening of the 1st instant, 
when he came up by railway to St. Mary's, he reckons that he 
lost a gallon. And indeed it was very copious, for on each of 
the first two days of his being here there was very nearly a pint 
of fluid, exactly like pure blood, with a vermilion froth on the 
top, in the porringers by his bedside. But a good deal of saliva 
was mixed with it, so much so at least as to prevent its coagula- 
tion, except in very small broken clots. On admission his mouth 
was full of clotted blood, which adhered to the gums ; on the 
tongue were half a dozen black vesicles of the size and shape of 
split peas, and blood was oozing from their edges. On the lips 
and face, on the hands, arms, and various other parts of the 
front of the body, were numerous black spots of about the same 
diameter as those on the tongue, but not raised above the sur- 
face. His urine contained blood, and, of course, albumen ; but 
I could not find that blood had been passed from the bowels. 
He said he felt weak and tremulous ; but he had walked to the 
hospital, and he sat upright, waiting for a bed to be prepared 
for him, for some time without faintness. There was color also 
in his cheeks and lips, and altogether much less exhaustion than 
one would have looked for after such severe haemorrhage. His 
appetite was not affected, and the bowels were open naturally 
without medicine. 

He was ordered ice, sulphuric acid and turpentine draughts, 
and " teacup diet" of milk and beef-tea, with a wash of logwood, 
catechu, and sulphuric acid, for the mouth. 

On the 3d there was little if any^ improvement in the local 
symptom, but his color and pulse had not failed. He was bid- 
den, in addition to the previous treatment, to keep in his mouth 
a lump of ice smeared with powdered tannin. 

On the 4th the haemorrhage from the mouth was not lessened 
much ; there was about three-quarters of a pint of froth-covered 
blood. It was stained brown by the local applications — in fact 
tanned. The pulse was quicker and weaker, about 108 in the 
minute and uneven. An ounce and a half of infusion of digitalis 
was ordered to be taken every third hour, and the sulphuric acid 
and turpentine were left off. 



PURPURA. 353 

On the 5th (yesterday) the pulse was 120 in the morning, 
110 in the afternoon, regular, even, and narrower than on the 
previous fc afternoon. The haemorrhage was not diminished. Sore- 
throat, faintness, and nausea were complained of. After he 
had taken six doses the digitalis draughts were given every four 
hours only. 

Late last night the breathing became short and difficult, and 
he died early this morning. Our secretary telegraphed to the 
poor man's wife at the village where they lived. The telegraph 
clerk was unable at first to deliver the message, there being 
several people of the same name in the place ; but hearing that 
a few days before a man bleeding much from the mouth had 
gone by train to London, he tracked him backward from the 
station to his cottage by the blood which had been spat upon 
walls and stones by the wayside. This shows that the account of 
the excessive haemorrhage before admission was not exaggerated. 

[A post-mortem examination was made on the 8th, two days and a half after 
death. The whole front of the body was covered with spots of purpura, of which 
those on the chest had pale-yellow centers. The rest of the skin was very pale, 
and there were very few spots on the back. There were numerous spots of pur- 
pura on the pleura, pericardium, small intestines, bladder, bronchi, trachea, and 
larynx. In the upper part of the latter organ they became more numerous, and 
in the fauces and tongue formed a continuous discoloration. On the tongue 
they were black and swollen as before death, and from the pillars of the fauces 
blood oozed on their being handled. There was no purpura on the oesophagus. 
The left auricle contained a firm non-adherent clot of fibrin, and there was 
another similar clot loose in the aorta. The heart was hard and firmly con- 
tracted. The ventricles are preserved unopened. The other viscera were quite 
normal in appearance.] 

Case 2. Jane N., aged nineteen, spinster, came in on January 
29. She has a transparent ivory complexion, firm large limbs 
and muscles, and an aspect of strength. She has always enjoyed 
good health, but during the last three months the catamenia 
have been very profuse, and have gone on lasting longer and 
longer, each period, till now she has hardly a week's interval. 
During the week before admission she several times found blood 
in her mouth, and on the 26th purple spots came out on the face, 
arms, bosom, and legs, and continued to' increase in numbers 
daily. They were of sundry sizes, from that of a mustard seed 



354 PURPURA. 

up to that of a pea, the smaller being far the most numerous. 
They were of an intense purple color, and presented a singular 
appearance from their striking contrast with her clear waxy 
complexion, the hue being perfectly complimentary. Their sur- 
face was not raised above the neighboring skin. I saw none on 
the mucous membranes of the mouth, but her gums looked a little 
red at the edges. 

Her bowels were regular. The urine could not be examined 
on account of the presence of the catamenia. She had lost her 
appetite, but I think that was accounted for by her sorrow at 
parting with her mother and coming into a hospital, as she has 
eaten fairly since she has found it to be not such a terrible place 
as she fancied. 

She was ordered the following : 

ly Dilute sulphuric acid, min. xxx, 
Tincture of digitalis, min. xv, 
Camphor water, fl. oz. j, 

every 4 hours. 
A teacup of milk or beef -tea every, 2 hours. 

On the morrow I found her appetite was not so entirely lost 
as she said ; so I ordered her broth and meat, potatoes and a 
lemon, and on February 3 ordinary meat diet. 

Twenty-four hours after commencing the medicine I pointed 
out to you that the center of each spot was lighter than the cir- 
cumference. It became distinctly yellow to the naked eye, and 
the dark color gradually faded away altogether by February 4. 
The sanguineous discharge ceased at the same time. She is 
quite convalescent, "but I observed that after an interview with 
her mother yesterday she was paler in the lips and depressed in 
spirits ; so I shall keep her in a little bit to watch against a re- 
lapse and give her a good rest. 

Case 3. William H., a butler, aged forty-five, was admitted 
on January 29 sinking with emaciation, anaemia, and pain in 
the cardiac region. The anatomical lesions found at the post- 
mortem examination oh February 3, were a dilated heart, with 
its mitral valve degenerated into wart-like growths, and kidneys 



PURPURA. . 355 

atrophied through the occupation of their substance by. many 
curiously large cysts. 

The imperfection of the mitral valve had been known before 
death, but that did not explain the disease ; and the circum- 
stances prevented any further diagnosis, or much association of 
the symptoms during life with the appearances on dissection. 

The chief causes of death do not therefore offer a profitable 
opportunity of clinical instruction, and I cite the case to-day to 
notice a secondary phenomenon. Two days before death there 
•appeared a large blotch of purpura on the nose, occupying the 
greater part of the feature, and another spot on the left hand, 
which was slightly oedematous. The discoloration remained in 
the dead body. The blood was fluid. 

These three cases present to you three aspects of purpura. 

In the first two the disease was due to a marked loss of func- 
tion in the capillary vessels, so that their coats were ruptured, 
and the contained fluid oozed out. In the first danger arose from 
the accidental location of this oozing in a loose surface, so that 
the haemorrhage was excessive. In the second there was no 
danger at all. In the third the deficiency of the capillaries was 
at a minimum, and would not alone have given rise to extrav- 
asation: but it was supplemented by the impediment to the cir- 
culation in the heart, and probably by the retention of urea in 
the blood. It was in itself unimportant. 

Like all diseases of the peripheral circulating system, purpura 
is most common in the parts most distant from the center. Such 
is the rule, though its want of universality is exemplified by the 
instances before us. But it is not most common in the most de- 
pendent parts, and in the legs it appears as often on the front as 
the back, on the body almost always on the front. This seems 
to remove its etiology from the category of being primarily trace- 
able to lesion of the central organ of circulation or of the mass 
of the circulated fluid. Were such its origin, it would appear in 
cases where the first is most affected, and in places where the 
latter is most abundant and most unhealthy. 

You must not fall into the old-fashioned error, inculcated when 



356 PURPURA. 

I was a pupil, of lazily attributing all illnesses where the blood 
is abnormal in composition to " diseases of the blood," and there 
ending it. The blood is like a pond or reservoir attached to some 
great manufactories : the refuse of the manufacture flows into it, 
and the engine boilers are fed from it ; waste products and latent 
power are mingled in its streams. If there is anything unusually 
foul in the water, the master does not lay the blame of that foul- 
ness on the innocent element, but traces it to defects in the pro- 
cesses drained and fed. So in purpura, the circulating fluid is 
probably always abnormal; but it is surely unwise to stop our 
explanation at this point, and to search no further. For the 
haemorrhage, whether free or into the cutis, makes it abnormal, 
and the degeneration of the red disks, discernible by the micro- 
scope, is just what is found in cases where there is no purpura. 
It is surely going backward, when the function we see to be de- 
ficient (namely, the retention of the blood) is a function of the 
capillary vessels, to say that their diseased contents are a cause 
of that deficiency. 

On this pathology is based the treatment. The less severe 
cases will recover under the use of cool, unirritating, but nutri- 
tious diet with vegetable and mineral acids, which astringe the 
capillaries. I think very possibly the young woman, Jane N. 
(Case 2) would have done so ; though not so quickly as she has 
now done, because mineral acids alone are slow to stop menor- A 
rhagia, with which, as well as with purpura, you will remember 
her to have been affected. But you saw that this treatment had 
no influence over the dangerous purpura of the first patient, 
although supplemented by other very powerful astringents. The 
most powerful remedy taken in both instances has been digitalis, 
whose agency in diminishing the area of the circulating system 
(probably through the functions of the involuntary nerves) I have 
often pointed out to you. Under its use the artery becomes 
smaller, the pulse-wave is narrowed and haemorrhage ceases. 
This happens not only when the haemorrhage is on the loose sur- 
face of a mucous membrane, but when it is subcutaneous. 

You saw the purple blotches on the young woman fade away 
at a marvelously quick rate ; and you saw them fade away from 



PURPURA. 357 

the center, not from the circumference, exhibiting yellow spots 
in the middle while the rim was still dark, thus proving that the 
action is not merely peripheral, but internal. At the same time 
you heard that the vaginal haemorrhage was equally ceasing, as 
it usually does in simple menorrhagia under the action of digi- 
talis. In the first related case there is no evidence of curative 
action, except the yellow centers to some of the blotches seen in 
the dead body. In the third case the purpura was such an un- 
important part of the patient's illness, that it had no treatment 
at all. 

The chief caution which I think it necessary to give you about 
the administration of this remedy is, that you should provide 
against the danger accruing from the sudden uprising of the 
patient. From the diminution of the area of the vessels so much 
less blood is sent up into the brain, that fatal fainting may ensue 
if the usual hasty demand entailed by this change of posture is 
made. The symptoms of deleterious action, and which warn us 
to suspend the employment of digitalis, are giddiness and nausea, 
accompanied sometimes by irregularity of pulse. Dilatation of 
the pupils, cold sweats, and complete syncope, alluded to in your 
books of materia medica, are late phenomena, which I have not 
had an opportunity of witnessing, and before the supervention 
of which you ought to have left off your drug. 

Digitalis seldom, if ever, begins to do harm till it has ceased 
to do good, and till therefore the necessity for it has passed. 
When the condition for which it may be wisely prescribed has 
passed away, then, and rarely before then, its poisonous power 
is exerted. And the more and more "the original morbid con- 
dition is departed from, so is the novel morbid condition, the 
poison by the drug, developed. Hence its action appears to in- 
crease. Metaphorically it maybe called "cumulative;" but the 
use of that word must not lead you to suppose that soluble alka- 
loids, such as those in foxglove, are likely to accumulate in sub- 
stance in the blood. The stricter explanation would be that its 
action is permanent, and therefore that each new dose adds to it. 

This account of the action of digitalis affords a reason for the 
plan which you see me adopt, of diminishing forthwith the dose 
directly that a beneficial effect has began to be produced. 



358 PURPURA. 



(Clinical, St. Marys, February 25, 1864.) 

Having very lately lectured on the subject of purpura, I shall 
bring before you, as an addition to that lecture, another case; 
though, as a fatal one and not seen by you or me during life, it 
is but little instructive taken singly. 

Two days ago a man, apparently of about thirty, was brought 
in evidently moribund, who was stated to have had "typhus- fever." 
He died an hour and a half afterward, without having manifested 
any diagnostic symptoms. At the post-mortem examination yes- 
terday, we observed on the dorsum of one foot a small spot of 
purpura, another at the side of the leg, and a good many more 
on the back. The largest were about one-eighth of an inch in 
diameter. The skin in many parts of the person was mottled, 
like that of a corpse when decomposition is commencing, the face 
was purple, and the scrotum was reddish purple as if bruised. 
The body was well proportioned, and there was a healthy quan- 
tity of firm adipose tissue in the walls of the belly. The heart 
was hard and large, weighing with the pericardium one pound 
ten ounces. The pericardium was universally adherent, as if 
from long-past inflammation, no connecting fibrin being visible. 
The valves were healthy, and in the cavities were contained the 
usual fibrinous coagula; there were none in the arteries or veins. 
No trace of chronic organic lesion was detected in any other 
organ. 

I show you here specimens removed from several of the viscera, 
which present a singular and uniform appearance, the differences 
being assignable generally to their different anatomical structure. 
Here are pieces of the brain, of the liver, and of the small in- 
testines, the kidneys, and the heart. You see scattered over 
them, inside and out, dark spots of purpura, such as I have de- 
scribed on the skin. This gives a very strange aspect to the 
kidneys, which look like the speckled belly of a trout. In a few 
of the spots the fibrin seems to have separated itself, forming a 
yellow center to the effused blood. There is no halo of inflam- 
mation around any of them. Many of the spots in the liver are 
more yellow than red. 



PURPURA. 359 

In the brain the spots are large, and branch out along the 
course of the vessels on the surface. In the right anterior lobe 
the nervous substance is broken up by a large black gelatinous 
clot of blood. It is evidently, as you may feel, of considerable 
size, at least twice as big as a chestnut, but I wish to harden it 
in spirit before I make a section. There are two more clots 
about the size of small peas at the back part of the hemispheres. 

No other abnormal appearances were observed, and this clot 
in the brain is enough to account for death. 

The history of the case, which I have since obtained, is as 
follows : The patient had previously suffered twice from acute 
rheumatism, and since November last had been badly off, living 
principally upon potatoes and bacon, but was in his usual health 
and spirits on the 18th instant. In the evening of that day he 
was attacked with sickness, pains in the joints, pain in the side, 
thirst and feverishness, which symptoms went on from bad to 
worse. On the 21st he was seen by Dr. Asprey, the medical 
officer of the Western General Dispensary, and found to have 
excessive pain in the joints and a brown tongue. In the evening 
he became delirious. On the 22d Dr. Asprey found him in a 
state of partial coma, but capable of being roused by effort, and 
certainly not anywhere paralytic. The tongue was dry and 
brown, and the pupils dilated. On the same evening he was 
brought to the hospital, as I have related, just before he breathed 
his last. 

This case shows how serious may be the consequences of 
purpura, a condition which, judging from the more ordinary 
examples seen by us, we are in the habit of rating low down in 
the scale of causes of mortality. 

In such a case of cerebral haemorrhage as this paralysis and 
apoplexy were not to be expected, because the central parts of 
the brain were not pressed upon, the sanguineous effusions taking 
their origin from and being confined to the surface. I remember 
the case of a young woman, who, after a mental affliction, died 
with typh-like symptoms not very dissimilar to this man's. 
There was found in the brain a clot of blood so large as to con- 
ceal the greater part of one hemisphere, but it was thin and lay 



360 PURPURA. 

quite on the surface ; so that I suppose it did not compress the 
inner portions of the cerebral substance ; for there had been no 
paralysis. It is not so much the size as the shape, and still 
more the situation of clots which make them apoplectic or not. 
A clot, one-tenth of the size of this, in the fornix or hippocampi 
would certainly have been apoplectic. 



LECTURE XXVII. 

ANJMIA. 

Part I. — History of a case of aneemia — Objections to the no- 
menclature of the disease — Its pathology — It consists of a 
functional deficiency of life in the blood-making organs — 
Application to this case — The defective morbid anatomy 
does not impede our treatment — Transitory curable states 
usually dependent on the mucous membranes, which have 
little post-mortal anatomy — Sketch of the active life of mu- 
cous membranes — Their importance in disease — Effect on 
health of their diminished vitality — Application of this pa- 
thology to practice — Intention of treatment to introduce ni- 
trogenous food ? iron, and chlorine — Mode of doing this, 
its effects, and reflections thereon. 

Part II. — Effect of ansemia on the mental faculties — Practical 
deductions. 

Part III. — Anaemia, when the result of permanent organic le- 
sion, amenable to the same treatment as when functional. 

(Part I. — Clinical, St. Mary's, November 15, 1861.) 

I am going to make the common and typical case of anaemia 
a text on which to hang a few practical observations on that 
disease. 

You will all remember the corpse-like paleness, made all the 
more striking by red hair, of a girl we first visited this day fort- 
night, named Margaret C. She smiled courteously, though 
quite unable to raise herself from the bed, and in answer to 
cross-examination, gave her history as follows : 

Her age is twenty, and she seems to have had generally very 
24 



362 ANAEMIA. 

good health, as is shown by her remembering that she had such 
an unimportant discomfort as a pain in the right side when she 
was a school-girl of seven. She was carefully brought up by a step- 
father in a higher class of life ; but three years ago she lost him, 
and had to go into service as a housemaid at the age of seventeen. 
For that work she was scarcely strong enough, and had been too 
tenderly nurtured; so after eighteen months' trial she gave it up, 
and was apprenticed to a Berlin-wool shop. There her mental 
superiority was recognized, for she quickly became forewoman 
with three girls under her in a shop at Maidstone. She felt the 
responsibility a good deal, and also thought the closeness of the 
shop did not suit her, although it did not seem to make others 
ill. However, she retained in her face a high color, for which 
she seems to have been somewhat admired, till nine months ago, 
when she began to lose it, and in a few weeks became as wax-like 
in hue as she is now. In the first stage of her ailing the appe- 
tite was large, so that she always felt in want of food ; but after 
three months it failed, then ceased entirely, and she took a dis- 
gust to all nutritious articles of diet. She had a good deal of 
pain in the epigastrium and to the left side of it, and also suffered 
from palpitations and pain of the heart. A quarter of a year 
ago she spat up some blood, and had a little cough, which fright- 
ened her much. Thrice during the nine months she has had 
attacks of low spirits with crying, but there is nothing abnormal 
in a girl being sad when she is out of health, or in her crying 
when she is sad, and Margaret C. does not appear at all hys- 
terical now. The catamenia had always been quite regular and 
sufficient till the commencement of the anaemia nine months ago, 
when they began to get scantier and scantier, and at last ceased 
entirely. The urine is pale and watery, the stools are scanty 
and steadily rare ; but there is never any sudden gush of bulky 
stools, no diarrhoea alternating with constipation, or other indi- 
cations of accumulation of faeces in the intestines. 

The patient expands her chest perfectly, and there are no 
signs to give rise to a suspicion of pulmonary tubercle, or at all 
events of tubercle in such a quantity as to account for the 
anaemia. There was at first a soft systolic murmur in the heart 



ANEMIA. 363 

when she was agitated ; but it went away after she had rested in 
bed five days. 

First, for the name by which I have already designated this 
girl's disease. Anaemia, or "bloodlessness," means in scientific 
language a deficiency in the red disks in the blood. The word 
has been objected to because it has been supposed to imply 
etymologically that there is a deficiency in the actual quantity 
of circulating fluid, of which deficiency in quantity there is truly 
no proof. And " spanaemia," or " thinness of blood," has been 
proposed in its stead. Such accuracy would be highly praise- 
worthy, if it were only accurate ; but really the mere fact of 
thinness does not hit the essential feature of the disease ; for the 
specific gravity of the blood might be raised as high as you like, 
but if you did not restore red blood-disks nothing would be 
gained ; the morbid state would still exist. In truth there is no 
occasion for fault-finding. " Anaemia," by the analogy of Greek 
etymology, does not mean deficient quantity of blood, but de- 
ficient quality, just as it is in Aristophanes, airpocuiros does 
not mean a man "without a face," but "with an ugly face," 
avapidfxoQ means " difficult to count," and so on in numerous 
instances of the use of the a privative. I shall therefore con- 
tentedly use the term anaemia to include all cases in which the 
amount of blood-disks is below the normal proportion. 

Anaemia has existed during life in the patients from whose 
bodies has been taken a great number of the organically changed 
tissues which you see preserved in museums and shown in lec- 
tures on morbid anatomy, and which may also be found out by 
diagnosis. In other cases of equal import and prominence 
anaemia is wanting. Again, very frequently you find it in a 
high degree in cases where there can be discovered no organic 
changes of the solids at all, and where from the transitory nature 
of the bloodlessness there is reason to conclude that such organic 
changes do not exist. Under this last category comes the 
patient who is the occasion of to-day's lecture. 

To understand how it is that so many causes are followed by 
the same effect and by an effect not at all proportioned to the 
general importance or want of importance of the cause, you 



364 ANEMIA. 

must reflect upon the true relation which the blood bears to the 
rest of the organism. It may be compared to a chief thorough- 
fare in a great city. Very few trades, still fewer manufactures, 
are carried on out of doors, or in the street itself, yet from the 
nature, the number, the pace, and other characteristics of the 
passing vehicles and people, a pretty shrewd notion of the com- 
mercial activity of the population may be formed. An observant 
foreigner standing in Cornhill and viewing the quick steady pace 
and careful yet healthy faces of the many-classed wayfarers, the 
well-packed loads of the vehicles, and their varied contents, 
could not fail to know that he was in the center of a prosperous 
trading nation. But it would not be, or ought not to be, the 
mere numbers of the people collected together that suggests to 
him the observation. On last Saturday he would have seen a 
greater crush than usual at the same place, but on inquiry he. 
would have found that it was only in consequence of all business 
being suspended for Lord-Mayor's day. And at \Naples, till 
lately, the lazzaroni and pickpockets who blocked up the pave- 
ments in the main thoroughfare were evidences of trade being 
not only stopped there, but made impossible by a horde of vil- 
lains. So that it is not the fact of crowding which should 
connect the idea of wealth with what is seen. 

In the blood the physician traces proof of constructive meta- 
morphosis (the city's manufacturing industry), destructive meta- 
morphosis (its consumption), and effective life (its social hap- 
piness) being carried on. But as our intelligent traveler, in 
estimating the wealth of a community, must not be deceived by 
an idle crowd at one spot, so the medical philosopher must not 
set down mere local congestion as proof of wealthy blood. In both 
experience finds strong presumptive evidence of something amiss. 

Neither must a mere bustling throng be reckoned as indus- 
trious citizens. There are cases where a large amount of solid 
matter, even where a large amount of red disks in active motion, 
adds no more to the usefulness of the circulating fluid than the 
lazzaroni to Naples, and which therefore, as far as treatment is 
concerned, are really in the same category as obvious anaemia. 
Of these I shall take a future opportunity of speaking. 



ANEMIA. 865 

But though crowds are no evidence of sound political health, 
yet it is certain that deserted streets prove political disease. So 
anaemia, or deficient redness in the blood, shows a deficiency of 
life in the ministers to that redness ; either the supply of food 
is too small, or its assimilation is defective; in either case the 
supply of red disks, either absolutely or relatively, is not com- 
mensurate with the existing demand. 

In many instances of anaemia it is easy enough to lay the 
finger upon the instrument of life which is to blame. We detect 
without difficulty causes at work to produce it — starvation, which 
anybody can understand, leads to an absence of the organic mat- 
ters made out of food; degenerated stomach, in which the ali- 
ments are not prepared for assimilation ; degenerated liver and 
duodenum, producing the same result; lesions of intestines or 
their glands, checking the imbibition of adipose matter, and so 
preventing cell growth ; changes in the spleen or lungs — organs 
which our physiological experiments, independent even of our 
observations of morbid phenomena, show to be answerable for the 
formation of new blood-disks in a way yet unknown ; mental de- 
rangement, care, disappointment — which so readily arrests the 
activity of the assimilating viscera; these agencies, and many 
more, are readily comprehended as causes of anaemia. But there 
are many cases where nothing obvious of this sort is to be made 
out, yet where the paleness of the blood seen in the face, lips, 
tongue, or in a drop taken from a pricked finger, and where evi- 
dences of it in fainting, weakness, palpitation, anasarca, amen- 
orrhoea, &c, are even more marked than where demonstrable 
lesion is to be found. So it is in the present instance. The 
young woman's history gives no reason to suspect any organic 
disease of the lungs or other organs, and the functions of life 
were fairly performed till she began to get pale and languid nine 
months ago. The want of red blood, which we look upon as the 
important feature in her case, also attracted her own attention 
particularly, as she had previously had an ornamental fresh 
color. Then, after an interval amply sufficient to enable us to 
separate cause and effect, come the symptoms which I wish to 
notice as the consequences of anaemia. Causes, no doubt, they 



366 ANEMIA. 

are in some instances, but here consequences. I mean the loss 
of appetite, impeded circulation, amenorrhoea, haemorrhage from 
the respiratory organs, and hysteria in a person previously unaf- 
fected in that way, which are noticed in the case-book. 

The only explanation she can give of her loss of health is her 
having been employed in a shop less perfectly ventilated than 
she had been used to, and having the main responsibility of the 
concern thrown upon her. Alone neither would have been suffi- 
cient, as the shopwomen under her do not appear to have suffered 
from the air; while, on the other hand, women engaged in retail 
business are not as a rule anaemic. But still I think that both 
together may perhaps be fairly charged with the blame, for while 
the increased mental labor was increasing metamorphosis, the 
the greater demand was not responded to by greater supply, but 
on the contrary assimilation was checked by the comparative 
unwholesomeness of the respired air. 

The not being able to trace deeper the anatomical cause arises 
from the imperfection of our knowledge, but it does not arise 
from neglecting to apply such knowledge as we possess to prac- 
tical medicine. If we were to make an autopsy of this patient 
instead of curing her, we should in all likelihood see no more 
solid lesions capable of accounting for her disease than we al- 
ready know of, we should probably find nothing abnormal in any 
part. So that you need not lament the opacity of your patients' 
bodies, or suppose yourselves likely to learn how to treat them 
better if you could see their insides. 

Anaemia without obvious organic lesion, when properly man- 
aged, is a very curable condition ; and this should still further 
reassure you that you miss nothing by not "being able to study 
its post-mortal pathology. Foi* passing and curable states leave 
but faint foot-prints behind them for anatomists. In a great 
majority of cases they depend upon morbid changes of the mu- 
cous membrane, of all the tissues in the body the one most 
speedily affected by decomposition after death, and then present- 
ing the worst possible picture of its condition during life. 

The intestines, as the anatomist sees them, are about as much 
like the intestines in health as the crumpled folds of dank parch- 



ANEMIA. 367 

ment which surround the mouth of a corpse resemble the same 
lips swelling with joy and expression. 

Let the picture which is painted on our minds be taken, not 
from the dead-house, but from the familiar view of our own 
mouths in a looking-glass; for one sketch drawn from the life 
is worth ten from the museum. Turn down the lower lip, and 
observe the infinite life going on. There is evidently as much 
blood as vessel; and seeing that blood, from the quantity of solid 
matter visible in it, has a right to be called a semi-solid, this 
membrane has an equal right to be thought of as a semi-fluid. 
And when we think of it as semi-fluid, let not the idea of a stag- 
nant marsh be presented to us, but of a headlong rapid. It is a 
useful way of keeping lively our feelings about the circulation, to 
examine through the microscope occasionally the toe-web of the 
slow-blooded frog. The action and ceaseless whirl of the living 
stream we see there quite drives us dizzy. What then must it 
be in our own warm selves ! If in a membrane so little animated 
as the frog's toe, or the bat's wing, which by the naked eye we 
should judge to be entirely devoid of blood, we still are enabled 
by our microscopes to see such a network of tubes conveying it — 
if in a creature, the greater part of whose blood is driven from 
the extremities to the center by the temporary fright we cause 
in putting him under a microscope, we find such a busy scene of 
circulation, what must be going on in a tissue glowing with red 
life and health ! 

To the fault of the mucous membranes I am disposed to lay 
the condition in which we find our present patient-. The two cir- 
cumstances to which I have traced the illness both act directly or 
indirectly on this tissue. The mental exertion involved in an 
unwonted responsibility thrown on a conscientious person would 
lessen the life of the involuntary muscles which carry along the 
mass of food through the alimentary canal. You know well how 
long your food is in leaving the stomach if you are called to an 
important midwifery case just after a hearty meal ; and several 
commercial and literary men have complained to me of attacks 
of vomiting (that is, temporary paralysis of the stomach) when 
they took dinner alone, and so were apt to let the mind dwell 



368 ANiEMIA. 

deeply on some interesting subject; and they have told me in 
wonder that they could dine out and eat and drink all sorts of 
rich things with impunity. They did not seem aware of the 
preservative value of frivolous conversation. 

At the same time that the moral causes thus impeded diges- 
tion, the unwholesomeness of the air in the close shop where our 
patient was employed poisoned the mucous membranes, diminish- 
ing the vitality of their epithelium, and causing them to be ab- 
normally covered with a thick layer of mucus. By this tenacious 
coating the entrance of alimentary substances into the veins and 
absorbents was impeded, and the owner pined in the midst of 
plenty. So all the usual signs of starvation followed. First 
hunger, — by no means a constant companion of chronic depriva- 
tion of food, yet sometimes present as here; then loss of appe- 
tite, a much more frequent phenomenon ; then paleness, languor, 
weariness, and pain in the stomach; then anasarcous oedema, 
and, in short, the other more marked symptoms of anaemia. 

You may observe that the loss in those constituents of the body 
which are of a nitrogenous chemical composition, is more marked 
than that in the hydro-carbonaceous fat. The reason is partly 
that the destruction of adipose vesicles is somewhat shrouded by 
the saturation of the tissue with serum, which gives it a false 
plumpness — partly that fat, being absorbable without much (if 
any) alteration, is easier taken up into the system than fibrin or 
albumen, which require a chemical solution before they can be 
absorbed. So that, though starved, Margaret looks but little 
emaciated. 

All that I have now said must have of course for its moral 
some hints on the treatment. My aim in anaemia is to introduce 
as quickly as I can the largest possible amount of (1) nitrogen- 
ous food, (2) iron, (3) chlorine. When I say "introduce," I do 
not mean "throw in," or get swallowed, but cause to be assimi- 
lated in the system. 

As regards the iirst, it is obvious that if I had written down 
ever so many "ordinary diets," one to whom the very sight of 
food was an abomination would have gained nothing by it ; she 
would simply have gone without. I directed no meals at all to 



ANEMIA. 369 

be taken, and no solid food ; but a cup of milk with a third part 
of lime-water in it to be given as medicine every two hours, and 
a pint of beef-tea in divided doses during the day. After two 
days she managed to eat an egg also daily, and after twelve days 
of gradual additions of this sort, you will find her on full allow- 
ance of mutton-chops, porter, beef-tea and milk. 

Iron is required to supply the anticipated new growth of red 
disks with their metallic constituent. You cannot force into the 
system in any way so certainly as by the " mistura ferri com- 
posita " of the pharmacopoeia. Large doses of the more soluble 
salts of iron have an action on the mucous membranes which not 
only prevents their being taken up, but also checks the digestion 
of other food. Evidence of the last-named effect is found in loss 
of appetite and feverishness, and in the rejection of iron and un- 
digested food among the blackened stools much sooner than when 
the drug is given in the form named. In spite of the elegance 
of preparations constantly put before us, and recommended for 
their solubility, such as the chloride, acetate, citrate, phosphate, 
and other salts of iron, I often prefer the unchemical mixture. 
It seems as if the carbonate which is preserved from decomposi- 
tion by the sugar, and the finely divided oxides diffused through 
the thick liquid, were peculiarly easy of solution in the water 
saturated with salts and carbonic acid, the solvent with which we 
have to do, not only in the stomach, but throughout the whole 
body.* 

I have found that some cases which did not get on so fast as I 
could wish under the above treatment, made a sudden start of 
improvement when to it there was added the administration of 
chlorine in the form of warm hydrochloric acid baths. More iron 
is taken up, the blackening of the faeces ceases, and it may be 
that the presence of more acid in the system retains more of the 
metal. In a few cases I tried for experiment's sake the hydro- 

* In reckoning the solubility of medicines, physiological pharmaceutists are 
apt to count the fluids of the body as distilled water, and because a substance is 
not soluble in that medium, to call it insoluble altogether; whereas, if it be 
soluble in water saturated with carbonic acid and salts, it is sufficiently soluble 
for the purposes of life. 



370 ANAEMIA. 

chloric acid baths alone ; and even then it was beneficial, seem- 
ing to confer muscular strength in the same way as the drugs 
which are commonly called tonic. On these grounds I cannot 
but think that hydrochloric acid supplies a distinct want in the 
system, that it is a directly restorative medicine in anaemia. 

It is not difficult to make this empirical observation accord 
with rational pathology. In anaemia the blood is more watery 
than natural ; the proportion not only of organic matters but of 
salts is deficient. Chloride of sodium is the most important of 
these salts, and the supply of one of the constituents of this ma- 
terial may be without fancifulness conjectured to be an aid to 
that renewal of life, which is the end of all medication. 

Besides the above-named medicines, you see that I have pre- 
scribed Pil. aloes cum myrrhd, gr. iv, omni node sumenda. Do 
not suppose that this is ordered merely as a purgative, or that 
any other purgative would do as well. On the contrary, most 
purgatives are injurious in anaemia. Gamboge, sulphate of mag- 
nesia, colocynth, mercury, and several others which produce 
elimination of serum and increase secretion generally, do harm 
just in proportion to their activity. It seems established, by the 
experiment of making them act as purgatives when injected into 
the circulation, that their soluble principles have a destructive 
agency upon the blood ; whereas the soluble alkaloid in aloes 
(aloine) is, in fact, a bitter tonic, and the purgative power of the 
drug resides in its insoluble resin.* Its action is very moder- 
ately eliminative — in small doses it slightly adds to the solid ex- 
creta of the colonic glands, and elicits faeces feculent in smell 
and of consistent form — while at the same time it retains by its 
bracing bitter the formation of mucus. See its action on moist 
piles, how it dries them up and makes them smart ! And judge 
from this what its action on the gastro-intestinal mucous mem- 
brane is likely to be. At the same time, by the more vigorous 
peristaltic action and by the solid mass passed along the gut, the 
already existing mucus is cleared away. Aloes is employed 
strictly as a clearer of the intestinal, especially of the colonic, 

* Headland on the "Action of Medicines," p. 331; and Robiquet, in the 
"Journal de Pharmacie" for April, 1856, quoted by Dr. Headland. 



ANAEMIA. 371 

( 

membrane, and it is joined with myrrh, partly to divide it mi- 
nutely and make a small dose go further, and partly to get the 
advantage of the extra resin. 

(Part II. — Clinical, St. Marys, January 23, 1863.) 

In a young unmarried woman, who leaves the hospital to-day, 
you may see an example of an occasional effect of anaemia to 
which I have not hitherto called your attention ; I mean its effect 
on the mental faculties. 

Margaret H., aged nineteen, a stout and well-made, but small- 
boned, girl from the City of Cork, was admitted at Christmas 
with pallor, palpitation of heart, oedema of ankles, loss of appe- 
tite, amenorrhoea, and some other of the usual symptoms of anae- 
mia without organic disease. She was not at all hysterical. She 
stated that she had been eight months in London engaged as a 
maid-of-all-work, and attributed her present illness to the hard 
labor entailed by that situation. She was ordered food every 
two hours and Griffiths' steel mixture thrice daily, and has been 
taking the latter up to the present time with the usual improve- 
ment to her health. So far she exactly resembles a class of 
cases, of which we admit two or three every week. 

The only peculiarity was her excessive sluggishness of body 
and mind. She would lie or sit for hours without moving in the 
posture she was placed in ; and if desired to walk dragged her- 
self along like a sloth. If questioned she sometimes did not 
answer, or confined her reply to rigid monosyllables. This slow- 
ness of nervous and intellectual power remained even after she 
had begun to regain color in her lips and cheeks; so that the 
sister and nurses set her down as naturally half-witted, and 
doubted the possibility of her gaining her livelihood as a servant 
even in the humblest capacity. As she possesses more than 
ordinary personal attractions, I dreaded sending out such a sim- 
ple-minded creature defenseless into the wicked world of London. 
But during the last week some accident has set her to work at 
crochet, and I found her fingers nimbly twinkling at this occu- 
pation, which it seems she had been accustomed to in Ireland. 



372 ANEMIA. 

She was encouraged to proceed, and to our surprise the manual 
operation, monotonous and mechanical as it seems to us, acted 
like magic; in a few days she became cheerful, laughs and talks 
to the patients, and has turned out a brisk girl of more than 
average intelligence. In consequence one of our hospital visitors 
has proposed to get her a place as lady's maid. 

Doubtless the way was prepared A _by the action of the iron in 
curing the anaemia, for a very slight extra restorative agent to 
enable her to regain her mental powers. Still I cannot but at- 
tribute very considerable influence to the habitual occupation, 
associated as it is with memories of her former happier life, 
taking her thoughts away from the dark noisy back kitchen of a 
small London shop to the old merry days in County Cork. 

There were here two deficiencies to be restored : first, that of 
red globules in the blood, which was effected by food and iron in 
the manner I have so often explained to you ; and secondly, 
that of the mental faculties; some new and brighter associations 
were required to excite her voluntary nervous system to action 
and to break the dull chain of her daily routine. Accident sup- 
plied this in the present patient's case, and with such good effect, 
and so strikingly, that I trust you may be led to make your 
reason in other cases take example, and do intentionally what 
was here done by a lucky chance. Occupation, and that not 
merely of an amusing character, but of sufficient interest and 
importance to require constant attention, is often a most valuable 
aid to treatment. I have known the little household duties which 
are a woman's function, even needle-work which must be done 
by a certain time, such as making a pair of slippers for their 
doctor, have a most beneficial effect upon the weakened mind. 

(Part III. — Clinical, St. Mary'' '$, February 6, 1864.) 

The cases entered as anaemia in the register are usually such 
as do not display signs of any organic lesion to account for the 
deficient supply of red blood to the tissues. And the knowledge 
that these patients are readily cured by iron is so familiar to 
you that it seems almost like a truism. I am not sure if you 



ANEMIA. 373 

equally entertain the fact that the same treatment is not less 
applicable to those whose defect is explained, either mechanically 
or physiologically, by some discovered structural change of a 
permanent nature. You are too apt to look upon this structural 
change as the main point to be considered, and in consequence, 
where it happens to be irremovable, you do not pay sufficient 
attention to such results of it as are really quite susceptible of 
cure. 

To illustrate my words I will call to your recollection a young 
woman who has just left the hospital. On January 8 Louisa 
0., an unmarried servant, aged twenty-five, was obliged to be 
sent up to bed with angemia of a very marked character. There 
was not a trace of red in her cheeks or lips even under the influ- 
ence of excitement. She was hardly able to stand upright, and 
the attempt to do so brought on great faintness and giddiness. 
The catamenia which last flowed, though at the regular time, 
were of a greenish color. She had palpitation of the heart, and 
had been getting paler for several weeks, but the inability to 
stand was only of a fortnight's duration. There was pain com- 
plained of in the cardiac region, and a loud blowing murmur was 
to be heard with the first sound. This blowing murmur was 
very audible all over the cardiac region and up the large vessels 
into the neck, but loudest and of a harsher character than else- 
where just at the level of the aortic valves. She could give no 
history of rheumatism, but had scarlatina some years ago. She 
was treated with iron mixture every three hours, and beef- tea 
and milk every two hours. On the 13th she was able to eat a 
mutton-chop. On the 16th the lips were getting rosy, and she 
was able to color up when spoken to. By the 27th she had 
gained a very fair color, even when not blushing, and she was 
discharged on the 29th. But the cardiac murmur remained as 
loud, if not louder, and was equally ringing in its tone at the 
level of the aortic valves. She went home registered as" cured" 
(for it had been indexed as a case of " anaemia"), was supplied 
with a large bottle of her mixture, and was advised every two or 
three months to take a ten days' course of iron in some form. 
She was warned also that mercury, purgatives, antimony, and 
all debilitating medicines were very bad for her constitution. 



374 ANOSMIA. 

I have no doubt in my own mind that this patient's central 
organ of circulation is in an imperfect condition ; and the special 
auscultatory signs induce me to think that the imperfect con- 
dition consists of a narrowness of the aortic orifice. It is true 
that she has never had any of the illnesses which usually cause 
cardiac lesion, and therefore I do not suppose the lesion to be of 
a degenerative kind. I should conjecture it to have more of the 
nature of an arrest of development. She is a puny, incompletely 
grown person, of slim figure, with narrow hips and hardly any 
bust, with fine soft hair and a delicate skin. Though turned 
twenty-five, she has rather the aspect of seventeen. I think it 
very likely that the aorta and its valves have not grown with hqr 
growth, but still retain the caliber suitable for a girl. She is 
consequently unable to do woman's work ; and even the usual 
monthly discharge from the uterus, which is a relief to the fully- 
formed female body, is too much for her. For the supply of 
blood to support such work is limited by the limitation of area 
through which it has to pass. 

Whether the aorta will ever make up for lost time, and, 
though late, accommodate itself to the body, I cannot tell. But 
I can tell by the results of this and similar cases that the watery 
blood is capable of renewal, though it be watery in consequence 
of a still existing cause. And if any agent ever removes that 
still existing cause, by renewing its imperfect life, I am sure that 
agent will be healthy human blood, the best medicine ever devised. 

The warning I gave her was directed against an unfortunate 
tendency, common to both the public and our profession, toward 
commencing treatment habitually with destructive remedies. 
They call this -' clearing the decks for action ;" in a majority of 
instances they throw overboard much of the best tackling in the 
ship and loosen her armor-plates. A so-called " sluggishness 
of the liver" is a frequent pretext. In a half-nourished person 
with pale blood, of course the fseces are light colored and 
ought to be scanty. Blue pill gives them immediately a darker 
color and increases their quantity, but sadly at the cost of the 
patient's strength ; while the temporary change soon passes off. 
Meat and iron produce the same result, by giving them more to 
be made out of, and the improvement is a real and permanent one. 



LECTURE XXVIII. 

PROMINENCE OF EYEBALLS. 

with commentaries — The pathology of the disease associated 
with that of anaemia, and the requisite treatment thence 

deduced. 



(Clinical, St. Marys, May 2, 1863.) 

A young woman who left the hospital yesterday exhibits one 
of the occasional accompaniments of anaemia in a marked degree. 
She is a subject of that state of the eyes called (somewhat bar- 
barously) Exophthalmia or Exophthalmos. 

Emily M., aged twenty-three, spinster, had been in since April 
the 10th. She is a leucophlegmatic flaxen-haired girl, but tall 
and well grown, "with great marble limbs." Her complaint 
was menorrhagia, which had began a month before by a slight 
attack of haemoptysis. Of this she was soon relieved by an 
ounce of infusion of digitalis three times a day, a grain of opium 
every night, and complete rest in bed ; and I am not going to 
lecture on that subject now. She has had two attacks of rheu- 
matic fever, the first when a child, the last two years ago. Four 
years ago she had measles rather severely, and since that date 
her eyes have gradually got very prominent. The prominence 
varies somewhat with her state of health, and on her admission 
was worse than usual. Her left eye squinted disagreeably out- 
ward, as is usually the case when she is in her worst state of 
health. On gently applying firm pressure with the fingers to 
the eyeballs, they may be got back to their natural place in the 
sockets, and at the same time the cellular tissue beneath the 
lower eyelid swells out. 



376 PROMINENCE OF EYEBALLS. 

There is a slight dullness on percussion, accompanied by bron- 
chial breathing, below the right clavicle. There is a loud systolic 
murmur in the heart, much most marked at the level of the 
aortic valves, and not affected by change of posture. 

This prominence of the eyeballs is a pathological problem not 
yet at all satisfactorily solved. There are four ways in which it 
has been accounted for : first, by describing it as an enlargement 
of the eyeball itself, a view advocated by Drs. Begbie and Stokes ; 
second, by its protrusion in consequence of hypertrophy of 
the tissues at the back of the orbit, as is maintained by Basedow; 
third, by a congestion and dropsical swelling of the same tis- 
sues, accompanied by want of tone in the ocular muscles, to 
which Mr. Cooper ascribes it ; fourth, by an increase of the fat 
which forms the padding of the globe, which Dr. Heusinger has 
found in two post-mortem examinations. These different views 
are described and enlarged upon in the "Edinburgh Medical 
and Surgical Journal" for 1854, page 426, where you will find 
full references to the literature of the subject. 

The first explanation certainly can apply only to exceptional 
cases. In those at present under my care no enlargement of 
the prominent organ can be detected ; nor in two patients I saw 
cursorily several years ago, do I remember to have observed it. 
Indeed, in the girl whose history I have just related, the globes 
are both rather small for one of her height and size. I can 
hardly imagine a tough, leathery sac, like the eyeball, swelling 
without a local disease of its coats, such as cancerous degenera- 
tion for example; and that would produce a disease of quite 
another class, and not to be confounded with the subject of this 
lecture. " Hypertrophy " of the tissues at the base of the orbit, 
suggested by Basedow, would imply a persistent and irremediable 
condition ; whereas I am sure that the eyes are at some times 
more prominent than at others, and that considerable improve- 
ment may take place. 

My own impression is that the slighter and incipient cases may 
be quite accounted for by relaxation of the muscles, and that 
would soon be increased by a consequent filling up of the tissue 
by fluid and congested vessels. I incline therefore to the opinion 



PROMINENCE OF EYEBALLS. 377 

given by Messrs. Cooper and Dalrymple, who attribute the dis- 
ease to this cause. 

At the same time it must be observed that Dr. Heusinger sup- 
ports his opinion as to its dependence on an increase of fat in the 
post-ocular space by two post-mortem examinations, in which he 
found that condition of things. And I do not see any incon- 
sistency in supposing that while the lighter cases are explicable 
in the way I have first advocated, the fatal and more protracted 
should exhibit a more permanent morbid change. The deposit 
of fat in the tissue is quite analogous to what takes place in parts 
which have been stretched or temporarily enlarged, such as in 
the mammae or abdominal parietes after frequent pregnancies, in 
old hernial sacs, in the scrotum after long-continued varicosity 
of the veins, in the ear and lips after they have been unnaturally 
stretched in accordance with savage ideas of ornament. 

I mentioned having two other cases now under my care. As 
it is rather a rare disease, I shall take the liberty of breaking my 
usual law for clinical lectures and of relating their histories, 
though I cannot enable you to verify them for yourselves. Mary 
B., a surgeon's daughter now aged thirty, first came to me in 
June last year. She had been for several years the unremitting 
nurse of an invalid mother, and restricted from the enjoyments 
almost essential to the health of her age and sex. For three 
years the catamenia bad been irregular, and sometimes absent 
for several months at a time. Her face and lips were pale, and 
her skin fair and delicate, easily flushing with excitement. Six 
months previously she had a severe pain in the region of the 
heart, and her doctor told her it was "rheumatism of the heart," 
and she had also suffered from palpitations. About that time 
she began to perceive a prominence of the eyeballs, and this had 
gradually become so marked as to make her uncomfortable by 
the observations it excited among her acquaintance. 

Examination of the chest showed the lungs to be quite healthy. 
The action of the heart was sharp, and there was a short harsh 
scrape audible toward the end of the first sound at the level of 
the aortic valves. 
25 



378 PKOMINENCE OF EYEBALLS. 

I ordered her to take an ounce of the following mixture twice 
a day: 

3^ Tincturse ferri sesquichloridi, 5y\ 
Stryehnise hydrochloratis, gr. J, 
Tincturse digitalis, 5j\ 
Misturee camphor ee, §x. 
Fiat mistura, cujus sumantur cochlearia ij maxima bis die. 

I kept her in London a few weeks as a rest, and since then 
she has taken every two months a three weeks' course of the 
medicine. She sends me word that now with the improvement 
of her general health the eyes have become much less prominent, 
and that she is by no means remarkable in her appearance. 

The other case is that of a puny woman of about fifty, who 
says she has been always ailing all her life, but never quite ill. 
She is the subject of a goitre of the central part and right lateral 
lobe of the thyroid gland. There is also a good deal of palpita- 
tion of the heart, but I cannot satisfy myself of the existence of 
any decided murmur. She is a very timid nervous person, and 
has some sort of fits, probably of an hysterical nature. I gave 
her iodide of potassium, and applied iodine externally to the tumor 
of the throat. But after three weeks it was but little, if at all, 
reduced, and she felt sure that her general health was the worse 
for the treatment. So then I gave her iron in full doses, and 
she seemed stronger again. She was at this conjuncture much 
thrown back by the alarm occasioned by a fire in her house. Her 
eyes are no better, but she is an unsatisfactory patient, and I 
question whether she perseveres in her medicine. 

Another case came under my care in the hospital during the 
first week of 1859:* 

Charlotte B., aged thirty-nine, a dressmaker, had been in poor 
health for more than three years, and had always been a weakly 
creature, of pale leucophlegmatic aspect. At the period named 
a swelling about as big as an egg came in the front of the throat. 
It was hard and had increased in size gradually to that of nearly 
three eggs at the time of admission. Latterly there had been 

* See Case Book XIX, p. 95. 



PROMINENCE OF EYEBALLS. 379 

strong pulsation in it, and it had caused occasional dyspnoea, for 
which leeches had been applied a week previously, with tempo- 
rary relief. She was hysterical and had a nervous cough of a 
spasmodic, noisy character. Both eyes were excessively promi- 
nent, and this prominence she said had first been observed a year 
before, and had increased up to admission. 

I cannot tell you much more about this case, as I was just then 
obliged to go abroad, but she is shown by the register to have 
left the hospital at Lady-day, and has not been again admitted. 
She has attended from time to time, however, as an out-patient, 
and finds the occasional course of steel she gets beneficial, or she 
would not come for more. I have seen her about in the neigh- 
borhood, and her eyes seem no worse. 

All these cases, and indeed all the cases recorded by various 
authors, so ably collected by Dr. Begbie,* however much they 
may differ in minor details, agree in connecting the disease with 
anaemia, and especially with those tendencies in anaemia to dis- 
order the heart and the growth of the thyroid gland. Experience 
seems to refer the goitre, the weakened heart, and the protrusion 
of the eyeballs to the same motive causes. They may not be 
connected with one another, but they are all connected with 
anaemia. 

Although, therefore, the direct mechanism by which the eye- 
ball is pushed outward may be obscure, it seems to me that we 
know enough about the ailment to be quite satisfied as to the 
right treatment, the most important point for both the patient 
and ourselves. Courses of steel and restorative diet, rest of body 
and ease of mind are the most effectual means of recovery, and 
seem to have been adopted by all those who have mentioned their 
treatment in the histories they put on record. 

In addition to this I should direct the patient to gently press 
back the eyeballs, and to wear a bandage over them at night. 

We know enough about the ailment also not to be alarmed at 
it, and to assure our patients that it is not of a nature in itself 
fatal to either life or sight. 

* "Contributions to Practical Medicine," 1862. 



380 PKOMINENCE OF EYEBALLS. 



{Clinical, St. Mary's, May 30, 1863.) 

Elizabeth M., aged sixteen, about whom I have been lecturing 
as having pneumonia and typh-fever, is worth observation also 
on account of the singular expression given to her face by eye- 
prominence. It seems she has always been a delicate child, and 
she has had several acute illnesses of which the last was rheu- 
matic fever, accompanied by pain in the heart, two years ago. 
There are clear signs of regurgitation through the mitral valve 
now heard by auscultation, but no other evidence of cardiac dis- 
ease. She is now flushed with the fever and pneumonia, but is 
generally pale, and is thin and weak looking. Though she is of 
full age, yet her mother says she has not yet been monthly, and 
her bust is quite child-like. 

This unnaturally protracted childhood is a frequent accompani- 
ment of valvular disease of the heart ; so common is the associa- 
tion, that it has not rarely been the very phenomenon which has 
drawn my attention to the heart ; and led to my finding out 
cardiac lesions before unguessed at. It continues often till after 
twenty years of age. I take the explanation of the facts to be, 
that from obstruction or regurgitation in the central organ blood 
enough is not spread over the body to carry out the functional 
development fitted to the time of life. Here you see a striking 
instance of it. 

In marked contrast to the undeveloped mammae is the throat 
of this girl. It has the full round form, swelling out in the 
middle and sides, characteristic of plump and perfect womanhood. 
On examination by the hand this is found due to a soft enlarge- 
ment of the thyroid gland — an enlargement which I told you in 
my last lecture on this point is very commonly associated with 
the eye-prominence of which our patient is the subject. 

Like the last instance we had of this disfigurement it is stated 
to be worst when the patient is ill, and indeed it has become more 
remarkable since she has been in the hospital ; as has also the 
goitrous swelling, which at first was scarcely perceptible. I 
mentioned to you before the same thing as occurring in the case 



PROMINENCE OF EYEBALLS. 381 

of a surgeon's daughter, whose eye-prominence is aggravated by 
severe dancing, long walks, and the like. Couple with this the 
fact that it entirely disappears after death, the eyes receding 
completely into their sockets, and I think you have evidence 
enough that however long and obstinate it is still a temporary 
curable disease ; and moreover, what is of more consequence, 
evidence enough to lead you to the means of cure, namely, those 
remedies which cure anaemia. This swelling of the thyroid is of 
a sort which will be more benefited by iron than hj iodine. 



LECTURE XXIX. 
ATROPHY OF MUSCLES. 

Part I. — Oases — Pathology — Treatment — Questions respecting 
hypertrophy. 

Part II. — Case of dropped hand from the poison of lead — 
Pathology of this form of paralysis and its connection with 
colic — Reasons for not considering its localization as de- 
pendent on the immediate absorption of lead — - Treatment 
with iodide of potassium, sulphur baths, splints, electricity, 
quinine, oil, and blisters — Which beneficial, which hurtful. 

Part I. — (Clinical, St. Mary's, June 13, 1863.) 

Nathaniel B. is a thin ascetic-looking man, of a faded-leaf 
complexion, aged forty -five. His expression recalls some stern 
" Bind-their-kings-in-chains" of the Great Rebellion, or those 
faces one sees in old Spanish monasteries, not in the flesh, but 
looking out of the grim canvas of a Zurbaran or a Ribrera. 
Nathaniel B. is a top-sawyer by trade, and was always a hearty 
fellow, able to do a good day's work, till ten months ago ; when, 
after violent exertion in turning over a mass of timber, he got 
what he calls " a wrench" in the pit of the stomach, and " has 
never been the same man since." The appetite failed and there- 
with the strength ; the muscles wasted, and the whole body grew 
emaciated. The loss of appetite then became entire, and then 
increased to an utter loathing of food. He went into Guy's Hos- 
pital three months ago, but left apparently dissatisfied and un- 
grateful. On gaining admission to St. Mary's, May 22, he seemed 
much cast down, expecting never to get any better. He was 
able to walk about, and the chief loss of power seemed in the 



ATKOPHY OF MUSCLES. 383 

shoulder muscles, the deltoid and biceps ; and when he tries to 
" put up" the latter, that is to throw into it the contractile 
nervous force, it feels quite soft, without any of the corky elas- 
ticity which distinguishes a sawyer's arm. He is the father of 
thirteen children, but since the commencement of his present 
illness, he has entirely lost virile power. He states himself to be 
a perfectly sober moderate man, and has a good character on that 
score from his employer. 

It is scarcely necessary to say that the epigastrium and hepatic 
region were carefully examined for evidences of cancerous de- 
generation, and none was found. The lungs also were well aus- 
cultated, and nothing abnormal was detected, beyond a suspicion 
of slight comparative dullness in the right apex. He had not 
suffered from habitual cough or had any diarrhoea. 

He was at first kept in bed and given milk and beef-tea every 
two hours, with ten grains of Boudault's pepsine powders three 
times daily. In a few days his excessive nausea and lowness of 
spirits had abated, and he was ordered six grains of quinine and 
three drachms of cod-liver oil daily in addition. In a few days 
more he was tried with half a mutton-chop, digested it well, and 
on the sixth of June was able to take our whole ordinary diet, a 
pint of milk, and a pint of beef-tea, and a pint of porter. On the 
12th (yesterday) he was so much better, that I thought it was 
scarcely justifiable to let him occupy a place in the hospital any 
longer, and I trust he will be able to get on as an out-patient. 

As he was confined to his bed at first, it was not convenient to 
put him in the scales, but on May 24, we found his weight 8 
stone 5} pounds ; on the 80th, 8 stone 7} pounds ; on June 6, 8 
stone 10 pounds ; on June 12, 8 stone 10} pounds ; his height 
being 5 feet 6 inches. 

The only day on which he did not take the pepsine was May 
29, when the stock was accidentally exhausted. He then com- 
plained of pain at the epigastrium and attributed that to the 
omission of the pepsine. 

This is a specimen of disease not quite so common as those I 
usually make the subject of my clinical lectures, and on that 
score not quite so interesting or important. Nevertheless it has 



384 ATROPHY OF MUSCLES. 

this importance, that if you do not understand its true nature, 
you will be very apt to treat badly tbe patients afflicted, and to 
make them worse. 

I have often told you that neglect of the powers our Creator 
has dowered us with is punished by their withdrawal : the intel- 
lectual sluggard becomes year by year more and more wanting 
in memory and judgment ; the arm of the Hindoo fakeer, tied 
upward for a few months, withers away ; and the calf of the 
Chinese belle or of the stiff-booted clodhopper is flabby and 
wasted. It is very important that you should know that the 
same penalty which is thus inflicted on willful underwork, is also 
exacted from overwork, voluntary or involuntary. -If a muscle 
is used so as to be worn out to a degree beyond that which the 
supply of nutriment is able to repair, or if it is so continuously 
used that there is no time for repair, it becomes degenerated, just 
in the same way as if it had not been used at all.* 

You saw in the Cambridge Ward two months ago a blacksmith's 
apprentice, of slight frame and with an imperfect aortic valve, 
whose arms, especially the right, had become atrophied from 
wielding too heavy a hammer. A few years ago I had in the 
same ward a patient whose chief employment was turning over 
large rolls of lead ; and the extensors of his right forearm had 
become paralyzed. About the same time a hard-drinking and 
hard-smoking, but hard-working, cobbler was under my care, 
who was unable to raise the arms from atrophy of the triceps and 
deltoids, muscles absolutely needed in giving the artistic, jerk to 
the thread which these workmen affect. But his legs, which he 
had rested, were strong enough. 

The following cases, exhibiting the same agencies in action 
under different circumstances, are from my private note-book. 

* And I am not sure, though for obvious reasons I should shrink from saying 
it to a mixed class of medical students, but what incautious intellectual work 
produces analogous results. How many men do we meet burdened, like little 
David would have been in Saul's armor, with more knowledge than they can 
wield ! Their minds seem day by day weakened by the stores they cannot use, 
so that they become less and less able to apply them. To how many of our pro- 
fession does the increase of practice bring the diminished, rather than the in- 
creased results of experience, if they do not sternly and conscientiously reserve 
to themselves time for " the sessions of sweet silent thought I" 



ATROPHY OF MUSCLES. 385 

E. C, aged fifty, had always been used to the regular habits 
proper for a London lawyer's wife, and not being fond of needle- 
work, had generally amused her leisure with reading. At that 
time her eyes somewhat failed, and she was advised not to read 
so much, especially in the evening. As an employment she set 
herself the task of knitting, first some strong nets, and then a set 
of drawing-room curtains. She worked several hours a day, 
fastening the work to her foot secundum artem, and drawing the 
thread upward. After a time she felt a weakness in the right 
shoulder, then a pain and stiffness ; being a very determined 
kind of person, she tried to work it off, rubbed and dowsed and 
shampooed her arm ; but the more she did so, the worse it got, 
and she was alarmed at last by the joint becoming exquisitely 
painful to the touch. Then her arm was put in a sling and tied 
up, she took steel and wine and nutritious diet and quite re- 
covered. 

M., aged fifty-four, has lived an active literary life, writing 
much and well. Her vigor of constitution is shown by the menses 
only lately beginning to grow scanty and irregular. But she has 
a theory of corporeal discipline not reconcilable with rational 
physiology ; she has thought to compensate for the exhaustion of 
mental labor by violent bodily exertion, and has been in the habit 
of occupying her leisure by furiously digging her garden with a 
masculine spade, and mowing her lawns, not with one of the ele- 
gant new machines, but an old-fashioned scythe. The conse- 
quence is that her good right hand has lost its cunning, and a 
letter she sent to seek my advice was scrawled with the left. 
The principal atrophy is in the deltoid and biceps muscles (those 
used in mowing), which are painful when moved, but not when 
pressed. She cannot raise her arm by independent efforts above 
the level of her waist, and it "feels out of joint if she tries to 
force it." Friction, brandy and salt, mustard, &c, have only 
made her worse. Her arm is now by my advice tied up, and she 
is taking quinine and steel and pod-liver oil in small doses. 

You may easily recognise in all these cases the same evil in 
action under corresponding circumstances — atrophy produced 
by local overwork of voluntary muscle. And if you think, and 



386 ATROPHY OF MUSCLES. 

examine closely the relations of the muscle to the rest of the or- 
ganism, you will see that this overworked tissue is in a position 
not very different from the underworked tissue, whose degenera- 
tion is so generally made the subject of remark by physiologists. 
The defect is in both instances a want of renewal. In underwork 
no demand is made for renewal, and in overwork the demand is 
made, but is not efficiently supplied. In the one the nerve-force, 
which should guide and govern the metamorphosis, is let lie 
asleep, and in the other has been so used up by unwonted toil, 
that it is exhausted, and for a time does not exist. So that the 
last effect on the muscular fiber is the same. No new store of 
muscular substance is laid in, and the old degenerates into 
inelastic fiber, and finally into a pale fatty tissue of still lower 
vitality. 

What is called "overtraining" in the prize ring has a similar 
pathology. The power of nerve over muscular fiber is capable 
of increase by education, so that it continues to brace it up more 
and more and to make the muscles harder and harder daily, till 
the " gladiatoria totius corporis ftrmitas''' is attained, probably in 
as great perfection in our days as in Cicero's. But the muscular 
fibers themselves are not capable of proportionate augmentation, 
and when the nerves have learned to exercise them up to their 
full force, are incapable of further improvement. If then the 
training is continued, the nerve-force expends itself in exciting 
the continuous functioning of the muscles, destructive assimila- 
tion exceeds the constructive; the body "eats into itself for lack 
of something else to hew and hack," and loses weight beyond the 
mere loss of fat.* Nerve-force is capable, as far as we know, 
of indefinite improvement; but the instrument it plays upon can- 
not be made stronger than it was originally intended to be, and 
when it is overstrained it degenerates. Hence premature decay 
is not rare among pugilists, boat-racers, runners, &c, whose 
ambition is greater than their powers, and those who live by 

* A moderate allowance of alcohol during training, by acting as an anaesthetic 
to the nervous system, tends to prevent this result. Modern trainers are apt to 
enforce too great abstinence, with immediate selfish advantage probably, but to 
the final injury of their pupils. 



ATROPHY OF MUSCLES. 387 

extraordinary exertions of physical strength have a short av- 
erage of life. 

The pathology is the same of that impotence of the generative 
and muscular functions which sometimes follows an active lfe in 
a tropical climate, and which cuts short the useful career of many 
of our countrymen in the East, and which is often unjustly at- 
tributed to lechery and drunkenness. 

But the most common examples of the disease are where it 
occurs in one set of muscles from special and partial overuse, 
such as we see in turners, carvers of ivory and hard woods, and 
similar handicraftsmen. 

Muscles affected with atrophy are in an unnaturally soft and 
friable condition ; they are pale colored, and look as if they had 
been macerated in warm water. They become like the muscles 
of a very aged person, and in fact the change is not much dif- 
ferent from a premature local old age. 

The change is usually first discovered by the patient in a much 
more sudden manner than you would have expected from its 
pathology. The "wrench" which our sawyer felt in his waist 
was not the real beginning of his ailment, but the last straw 
which broke the horse's back. And often painters will tell you 
that they went on earning full wages till a certain day, when they 
became utterly unable to raise their hand. 

Pain is a variable symptom. Where one or a few muscles 
only are affected, it is a pretty constant accompaniment, and is 
usually set down as rheumatism, or as stiffness, the result of 
cold. In our present patient, where many muscles were more 
or less acted upon, it was absent, or so generally diffused as to 
produce rather a feeling of mental depression and malaise than 
of local distress. 

Muscular atrophy and local paralysis will sometimes follow 
chronic poisoning by malaria. I have a strong impression that 
those are right who locate in the nerves the chief injury inflicted 
by such agencies as cause ague and its allied disorders of inter- 
mittent type. I am not therefore surprised at finding loss of 
nervous function, either in the form of neuralgia or paralysis, 
which can be attributed only to the poison above named. The 



388 ATEOPHY OF MUSCLES. 

only thing which distinguishes the paralysis from the other forms, 
of aguish disorder, and consequently obscures the diagnosis, is 
that it is not intermittent. 

The treatment follows as a matter of course from the pathol- 
ogy. It consists, in the first place, in enforcing complete rest 
of the diseased parts, in no tallowing them to have even the labor 
of supporting the members they belong to. The dropped hand 
we fasten on a splint; the paralyzed humerus we put in a sling, 
taking care that the elbow is well supported and does not drag 
upon the shoulder; this patient, who is the text of my lecture, 
we put to bed and kept him there a few days. Then we admin- 
istered animal food in a form by which the patient takes as much 
as the stomach can possibly digest. In this instance there was 
utter anorexia ; so beef-tea and milk were swallowed in medicinal 
form every two hours. To aid in digesting it pepsine was ordered 
three times a day. To supply a basis for molecular growth, cod- 
liver oil was given, as soon as the nausea was beginning to abate. 
And quinine was added to brace the mucous membrane up to its 
duty of absorption. I have not prescribed iron, but it would be 
quite rational to do so now that the intestines have begun to re- 
cover tone. 

Where the pains are severe, cold douche baths and cold water 
compresses give more relief than anything else. Warmth and 
stimulating embrocations seem to do harm. 

Where malaria has been to blame, you must be careful in 
desiring your patients to avoid the dew-times — "when the mists 
arise that have strength to kill." A Roman proverb warns the 
native against the hour before and the hour after both sunset 
and sunrise, and many a stranger has suffered in that climate 
from a neglect of popular experience. In England the healthy 
population is not debarred from the sweet influences of these 
romantic hours, but those who have once suffered from malaria 
must remember that they are more than ordinarily liable to a 
fresh reception of the poison. 

You may be tempted to inquire, if overuse of voluntary muscle 
causes atrophy,^ and underuse also, while moderate use leaves 
our frames well proportioned, what sort of use is it which induces 



ATROPHY OF MUSCLES. 389 

hyper trophy. I confess that, in spite of the decies repetita state- 
ments of physiologists, who have been copying one another from 
the time of Galen, I do not know that any kind of use at all 
does so, in the sense of making the substance of the muscle 
larger when measured in a state of rest. Doubtless an actively 
employed biceps or gastrocnemius will more readily be acted 
upon by the voluntary nerves, will contract more strongly, and 
be harder and more prominent when contracted ; but I cannot 
find that it grows at all bigger. I do not absolutely deny the 
existence of the physiological hypertrophy of muscle; I only say 
that at all events it is very rare, for I cannot find any instance 
of it. 

The most notable example of muscular hypertrophy ought to 
be an active, well-made, one-legged or lame man ; seeing he uses 
one leg instead of two, it ought surely to be enlarged. Yet in 
measuring in several instances the remaining leg in a state of 
rest, I cannot find that the proportion which it bears to the arm 
is at all different from the proportion in ordinary persons of the 
same build. And I cannot find that as a rule blacksmiths' arms 
are out of proportion to their legs. Both are muscular ; for 
none but a muscular man can work at such a trade, and wnen 
excited, the brachial muscles contract firmer than those of the 
lower extremity, and are more marked ; but they are not dispro- 
portionately large when relaxed. 

Of course you will find employed in occupations where excel- 
lence may be attained by the special exercise of one set of mus- 
cles, men who have those parts well developed ; but they are so 
developed originally, and not by the trade. Big-armed men 
become pugilists, big-legged men acrobats ; but they do not 
become big-armed or big-legged because they are pugilists and 
acrobats. 

Sometimes the development is strangely out of accord with the 
occupation ; the wrong man gets into the wrong place. I give 
you the measurements of the upper extremities of Cordonnier, 
an horticulturist at Lisle, who has a most extraordinary develop- 
ment of the muscular and bony structure. He is not fat, but 
hard and firm, weighing in his clothes but sixteen stone, yet the 
circumference 



390 ATROPHY OF MUSCEES. 

iches. 



of the neck 


is 18 


" breast 


"44J 


" forearm . 


" 13 


" wrist 


" 81 


" palm of hand . 


" 111 



How were these Herculean thews bred ? In strangling drag- 
ons, stunning wild bulls, cleansing Augean stables ? Did their 
owner — 

" Tear the lion as the lion tears the kid, 
Run on embattled armies clad in iron, 
And weaponless himself 
Make arms ridiculous ?" 

No — they are employed in tying up ladies' bouquets, for his 
skill in which accomplishment Cordonnier is famed. I have 
never heard of an hypertrophy like that being due to overuse. 
Where the hypertrophy exists in voluntary muscles, I suspect it 
is due to a congenital peculiarity, and not to occupation. 



g (Part 11.— Clinical, St. Marys, October 31, 1863.) 

In Benjamin Franklin you have an example of a disease you 
will very often have to treat, if your practice lies among arti- 
sans, the " dropped hand" of painters and glaziers. He has 
been employed in the carriage building department of the Great 
Western Railway, and is an old-looking man, though only forty- 
five. He has been a spirit-drinker, but never gets actually 
drunk. He has had gout off and on for the last ten winters, and 
used to take a great deal of colchicum. He found however 
that drug to produce symptoms resembling those of delirium 
tremens, and has given up the use of it in favor of iodide of 
potassium, which agrees with him well.* On September 28 he 
gave us the following history. He had been first taken ill three 
weeks previously with crampy pains in the belly, which got worse 

* His plan is this — when the gout comes on he buys four pennyworth, or a 
drachm, of iodide of potassium, dissolves it in a pint of water, and takes it in 
the twenty-four hours. 



ATROPHY OF MUSCLES. 391 

in spite of castor oil, till the 28th. About the same time his 
hands began to droop, and when we took him in hand, at that 
date, he could not raise them on the wrist at all. There were 
also severe pains in the calves and thighs. The gums had a 
livid line, characteristic of saturnine poisoning, to the breadth of 
an eighth of an inch round the teeth, and the description he 
gives of his employment shows that he is much exposed to the 
influence of white lead. Besides using white-lead to form what 
is technically called the " body" of the color laid on, he has also 
employed mercurial colors in the fine work required. And this 
addition of mercurial to saturnine poisoning, or perhaps his bad 
habit of spirit drinking, caused a little peculiarity in the case, 
which was observed on his first admission : his arms were noticed 
to tremble when he held them out, as if afflicted with paralysis 
agitans. This peculiarity soon passed away, and there is 
nothing else to take the case out of the category of typical and 
ordinary instances of disease, such as I endeavor to select for 
my clinical illustrations. 

I am disposed to explain a great part of the pathology of 
painter's dropped hand on the same principle which I stated to 
you on a former occasion apropos of simple muscular atrophy. 
The white-lead is slowly absorbed by its gradual and sparing 
solution in the fluids of the body, which are rendered capable of 
dissolving it by their saturation with carbonic acid. In the 
blood it destroys the red globules, and carried to the muscles 
removes their red color also, and renders them incapable of 
contracting except under extraordinary nervous influence. This 
paralyzing effect is most commonly shown in the involuntary 
fibers of the intestines, producing the well-known painter's colic. 
There are two reasons why it should be exhibited soonest on 
these intestinal fibers : first, they are the nearest to the usual 
portal by which the poison enters, the path of the food ; sec- 
ondly, they are weak muscles, and yet have constant, almost 
unintermitting work to do, so that they can have but little repose 
during which recovery from exhaustion might be possible. 
Hence colic and constipation from arrested vitality in the intes- 
tines are the commonest results of lead poisoning. 



392 ATROPHY OF MUSCLES. 

To the muscles of voluntary motion in the trunk and limbs 
the same principles apply, and most especially the latter. Those 
muscles become most paralytic which are most exhausted by 
the peculiar employment of the individual. I had a patient a 
few } r ears ago whose work lay in a sheet-lead warehouse, and 
consisted of moving very heavy masses of that weighty metal. 
He became gradually paralytic in the right forearm, and weak 
in the loins, parts extraordinarily exhausted by his labor. 
Painters, especially fine painters, such as those employed upon 
carriages, do not use the biceps, or the shoulder, or the dorsal 
muscles more than other people ; but they do use excessively the 
extensors of the hand. Try for yourselves the drawing of fine 
lines on a wall with the arm free, and you will find how pain- 
fully tired the outside of the forearm soon gets. Artists usually 
rest the wrist on a mahlstick, with the result of saving these 
muscles, and seldom get paralysis. But for some reason or 
another artisans generally adopt another plan of gaining the 
requisite fulcrum for steadying the line ; they fix the hand by 
means of the fourth and little finger on the plain surface, calling 
the support thus obtained their " compass," and then wield the 
brush with the thumb and forefinger. This throws a terrible 
strain on the extensors of the wrist, and they suffer accordingly. 
The overexhausted fibers become atrophied, pale, and paralytic ; 
while other muscles escape, although equally exposed to the 
baneful influence of .the lead, but not so much used. 

I am not certain whether the neighborhood to th,e paint has 
much to do with the hand becoming paralytic. At first sight 
one would be disposed to think it had. But then on reflection 
you will observe that other muscles which are equally near, such 
as the flexors, do not become affected ; and others which are still 
nearer also escape. A dropped hand can often twiddle its 
fingers with their interossei and lumbricales, bend in its thumb 
with its adductor pollicis, and even exhibit the delicate action of 
the palmaris brevis. Now, the fibers of these muscles have but 
a layer of skin and dirt between them and the paint during the 
whole of working hours, whereas the forearm is scarcely even 
directly exposed to it; for it is very unusual to see fine painters 
tuck up their shirt sleeves, and the majority even work in their 



* ATROPHY OF MUSCLES. 393 

fustian jackets; yet it is the forearm that becomes affected, and 
not the more directly exposed muscles. 

This man was treated with iodide of potassium, to bring the 
lead remaining in him into a soluble form capable of being re- 
moved by the fluid excretions. He had also sulphur baths thrice 
a week to test the progress of this removal of the poison. For 
ten days the secretion of his skin in the delicate places (such as 
the axillse) was stained blackish with each bath from the sul- 
phuret of lead formed. But after ten days the stain was no 
longer visible ; and at the same time the livid line round the 
gums began to vanish. He was losing his lead — the cause of the 
disease was being removed. 

Yet though the cause was being removed, the disease remained, 
and indeed still remains to a considerable extent. The treatment 
applied to it has been first — rest. The hands are placed on 
splints for the greater part of the day and night, so that their 
weight may not drag upon the muscles. Secondly — intermitted 
motion. Electric shocks are passed through the muscles for a 
short time daily. Thus the atrophy of overexertion and the 
atrophy of disease are both guarded against by imitating the 
most healthy natural circumstances of rest and motion. 

He is also taking quinine and cod-liver oil, to furnish a basis 
of molecular growth for renewed muscular fiber, and with this 
treatment he has decidedly improved in general health, and is 
able to raise the wrists much better. 

But while I tell you what has benefited him, I should also tell 
you of one thing which in both his and my own opinion has done 
harm. As an experiment I treated the forearms for three days 
with small flying blisters, never allowing them actually to pro- 
duce vesication, but to be moved onward when the skin became 
reddened. The paralysis was certainly worse during this appli- 
cation, and for several days afterward, so of course I shall not 
repeat it. What I have previously mentioned to you constitutes 
the ordinary and typical treatment of dropped hand, and, 
though I mention it as a part of the established treatment in my 
systematic lectures, I have always felt doubtful in what sort*of 
cases blistering is beneficial, if any. 
26 



LECTURE XXX. 
CHOREA. 

Part I. — Case treated without drugs — This case a recent one — 
Principle >of treatment. 

Part II. — Four long -continued but curable cases treated with 
arsenic — Quoted as specimens of the disease as usually seen 
— Effect of forcible control over the movements. 

Part III. — Records of three fatal cases and two unaffected by 
treatment — Connection of chorea and rheumatism and disease 
of heart statistically deduced from the records of thirty -three 
cases under my care. 

Part I.— (Clinical, St. Marys, February 20, 1863.) 

A lad of nine, Henry G., was taken in on the 19th of last 
month for chorea. His parents stated that the attack had come 
on suddenly a week previously without any assignable cause and 
while he was sitting at dinner. It began by convulsive move- 
ments of the arms and facial muscles, and very soon the whole 
body became affected. As he lay in bed I think I never saw 
more violent and uncontrollable motions of the limbs and body. 
He was never still, but speaking to him or touching the bed ex- 
cited convulsions in the same electric manner as in hydrophobia, 
and judging by his wailing they seemed to be very painful. He 
was unable to retain his faeces or his urine. He was stated to 
have been subject to worms, as is the case with half the children 
of our laboring classes ; so I gave him once and again a stout 
jalap, aloes, and calomel purge to ascertain the fact; but no 
worms or mucus appeared, nor had there been any collection of 
old faeces in the colon. Beyond that he has had no medicine, 



CHOREA. 395 

except on one occasion a little catechu to solidify the stools, 
which were passed involuntarily, and prevent them dirtying the 
sheets so much. Yet you have seen the chorea pass away en- 
tirely, so that on the 14th instant the case-book records that he 
carried the inkstand steadily round the ward for us, handing it 
with one hand, and he has been making himself useful to the 
sister by serving out patients' dinners. I have kept him in the 
hospital till to-day, solely to see if any relapse would occur. 

I said he had no medicine for the chorea, but I did not say he 
had no medical treatment. He was surrounded as he lay in bed 
with toys, and he was induced to make every effort to retain them 
in his hands. In two days he began to get quieter, but not much 
more advance was made, till his regaining some power over the 
sphincters enabled us to have him dressed and to set him to walk 
in measured step about the ward. Then we imperiled our 
crockery in a good cause by letting him carry it about and clean 
it, till he rapidly acquired the steadiness you saw him exhibit a 
week ago. 

The object aimed at was to draw off his attention from his 
miserable state, to concentrate the psychical forces in the en- 
deavor to acquire power over voluntary muscles, and thus to 
renew their lost control. 

Chorea is obviously not a disease which must necessarily go 
on from bad to worse if unarrested by drugs. The long list of 
varied remedial agents employed, many of them repugnant to 
one another, is enough to make us suspect this. Dr. Reeves, in 
his statistics of eighty-four cases occurring in the Norwich hos- 
pital, states that the shortest duration of the disease under 
pharmaceutical treatment was two weeks; the longest eight 
months ; and the common average, seven weeks.* I suspect, 
though I have no statistics to show it, that the common average 
of duration of recent cases, where no drugs are taken, would be 
very similar. 

The pathology, or explanation of the immediate internal cause 
of chorea, is quite unknown. Sydenham ascribes it to a " humor 
thrown upon the nerves." In three fatal cases I have seen, the 

* "Edinburgh Med. and Surgical Journal," vol. viii, p. 314. 



396 CHOREA. * 

nervous system seemed perfectly healthy ; in one there were 
tubercles in the spinal cord. Dr. Cullen thought that the malady 
depended on " a state of mobility" of the system ; that is to say, 
that the limbs move about too much because they are too movable. 
Dr. Marshall Hall attributed it to "reflex action;" but talking 
of " reflex action" is merely to class the phenomena of convulsions 
under a common name, for nobody has yet dissected out the 
" reflex" nerves. 

You may observe that in chorea the principal muscle in any 
intended motion is pretty fairly obedient to the will ; the lad, 
when he was bidden to put out his arm, put it out ; but those 
muscles whose motions are normally associated with the princi- 
pal one, did not act ; he did not put it out straight, and twisted 
it in every direction but the correct one. Hence Darwin classes 
it among " diseases (defects) of association," that is to s"ay, cases 
where the necessary connection between certain vital acts is 
overthrown. 

The existing or external causes are sometimes easier to dis- 
cover. You have cases where the patient is anaemic, is teething, 
has mucous intestines and disordered alvine secretions impeding 
digestion, skin eruptions, retarded catamenia, pregnancy, dis- 
eased bladder or uterus, perineal fistulse, tubercles in spinal cord. 
(In these three latter cases I am recalling to my mind examples 
of fatal termination.) Many others again attribute the disease 
to fright. In such instances you find that the chorea obstinately 
remains as long as the existing cause does, and on its departure 
begins gradually to decline. Under such circumstances the plan 
of treatment is obvious enough ; you must turn your efforts to 
the removal of the exciting cause, if it is removable, and then 
expect with confidence that the chorea will disappear in about a 
fortnight. If the exciting cause is irremovable, or if (as in the 
case of pregnancy) it is too valuable to be got rid of, I cannot 
find that specific drugs do any good to the chorea. 

But in a very large number of cases you can discover no 
exciting cause. Perhaps it has passed away; perhaps even if 
you had watched the patient all along, you would not have dis- 
covered it on account of its secret nature. In such cases I have 



CHOREA. 397 

usually been in the habit of administering arsenic ; but really I 
cannot say that any patients under arsenic have ever passed 
from a severe state of chorea to one of complete voluntary con- 
trol more quickly than this boy without arsenic. 

You may say truly that chorea exhibits sometimes a tendency 
to become chronic in cases where the general health only has 
been attended to. But I do not think that proves anything 
against my idea of its nature being to get well of its own accord. 
I believe that in these protracted cases there is a continual re- 
newal of the cause of the disease ; that it is in fact kept up by 
injudicious management. One of the most common forms of 
injudicious management is the fixing of the patients' attention 
upon the deficiency of voluntary control. They are told, and 
wondering by-standers are told, often with exaggeration, how bad 
they are ; the malady is painted in heightened colors ; pitying 
friends offer unnecessary help; cruel companions ridicule their 
infirmities; till, like the subjects of electro biology or mes- 
merism, they lose control more and more from being told that it 
is lost. You may see this mental cause of the aggravation of the 
disease most clearly shown if two or three choreic patients chance 
to be put together in the same ward. It is impossible to avoid 
it sometimes, but you will observe that they always make one 
another worse. If one is getting better, she will be immediately 
thrown back again by the introduction of a new companion simi- 
larly affected ; and not rarely a patient previously free will catch 
it by the contagion of the eyes. 

The influence for you to exercise is the very reverse of this; 
you must encourage the patients to make every exertion to direct 
the movements of the limbs, and let them perceive as little as 
possible their deficiencies in this respect. Above all, let them 
avoid looking-glasses or the depressing sight of other unfortu- 
nates- in the same condition. Poor persons are best treated as 
in-patients of a hospital, as the advantage of getting them away 
from their injudicious friends outweighs the risk of possibly 
coming in contact with other choreics. If the patients are not 
in a position of life to make this resource available, at all events 
get them away from home as soon as possible. Sent under the 



398 CHOREA. 

care of a judicious governess to the seaside, or anywhere else for 
an excuse, many children recover rapidly, who at home would 
have gone on relapsing and relapsing again every week. 

Slow walking in timed step is excellent practice for regaining 
directing power, and I dare say slow music and solemn minuets 
would be equally efficacious; you may remember that the Taran- 
tella was so called from being used to relieve a nervous affection 
falsely attributed to a poisonous spider.* Carrying trays and 
crockery, and other things that demand care, assists the cure. 
In short, using the will contributes more than anything else to 
its renewal, and is the only real " specific" for chorea, when once 
the original exciting cause has been removed. 



Part II.— {Clinical, St. Marys, May 30, 1863.) 

Maria S., aged thirteen, was received May 1 with very severe 
chorea of six weeks' duration. No cause could be assigned by 
her mother, nor could any worms be found in the faeces, but, from 
her dirty and neglected appearance and the unnatural smell and 
color of the alvine excretion, I have no doubt she has been fed 
on diet very unsuitable to a growing girl. The muscular move- 
ments were so excessive as' entirely to prevent her speaking in- 
telligibly, but she was quite quiet when asleep. She is a thin 
but healthy looking child, and the only abnormal phenomenon is 
the fetidity of the stools. She was kept for six days without 
medicine to observe the case, and no improvement was found 
from the better food and discipline of the hospital. She was 
then put upon four minims thrice a day of liquor potassae ar- 
senitis, and immediately began to get better. On the 9th she 
could walk up and down the ward and feed herself, and is now 
able to assist in washing up the crockery, and will leave the hos- 
pital shortly. 

* In Kircher's specimens of Tarantella tunes the first are merry jigs, but the 
last is like a funeral march, and must have been composed, as one would guess, 
for some church dignitary affected with the curious contagious chorea of the 
fifteenth century. See Hecker's "Epidemics of the Middle Ages." — Dancing 
Mania, p. 172. 



CHOREA. 399 

Along with the last patient I also took in Richard B., aged 
nineteen, a chairmaker. Three months previously he had been 
obliged to walk home four miles in the dark, of which he had 
from childhood been much afraid. He was overwhelmed v/ith 
fright, but concealed his fears out of shame. After this he be- 
came very nervous, and chorea gradually came on. The chorea 
increased so much, that for six weeks he had been unable to work 
at his trade. He is very thin and pale, with blue cornea to his 
eyes. He was put upon misturse ferri §j ter die, to which has 
been added since 5j of cod oil. And he has also now a shower- 
bath every morning. On the 9th he was steadier than on ad- 
mission, but then the improvement became stationary, so that I 
resolved to treat him also with arsenic. The quantity has been 
gradually increased up to TT|xvi of the liquor potassse arsenitis 
three times a day, and he has been slowly but steadily improving. 

A third patient, Emma B., aged fifteen, has been under my 
care only eight days. The catamenia had occurred for the first 
time two months previously, and about the period when they 
ought to have been again present she was observed to get rest- 
less and fidgety. In a fortnight's time this restlessness became 
complete chorea, which was the prominent disease on admission. 
The movements were then almost entirely confined to the right 
side of the body. Two nights before admission she had an hys- 
terical fit, but this had not before or since been observed. After 
she had been in hospital a few days we found that the chorea 
came on in paroxysms of about two hours' duration, during which 
it was very violent over the whole person. In the intervals she 
was comparatively quiet, and could speak easily, though not 
extend the right arm straight. 

I ordered at first valerian, which seemed to do no good, and 
now she is taking arsenic like the others. She has also in addi- 
tion a warm hip-bath nightly. 

These are interesting cases for you to watch, for they present 
examples of the disease when it has already assumed a chronic 
form, and when the mere fact of its existence makes it reproduce 
itself, if I may so express myself. I mean that the constant 
movement and annoyance arising from the chorea still further 



400 CHOREA. 

weaken the already weakened and predisposed body, and so in- 
stead of tending to recovery naturally tend to a prolongation of 
the malady. In this stage it will not get well without some 
strong measures in the way of drugs. You saw that the child 
Maria S. got no better during the week that she was treated by 
diet and discipline alone. We must have recourse to the phar- 
macopoeia. 

One very powerful aid is iron, and a great many cases may be 
cured with that remedy, either in the form of the red rust or of 
Griffith's mixture. But you saw that iron was beneficial only 
during the first two or three days to the boy Richard B. And 
the disease may come on even while a patient is taking iron. 
It did so a few years ago in a boy in this hospital, for whom I 
had prescribed that mineral for tubercular consumption (No. in 
Register 8627, November 13, 1857). Nevertheless he got well 
of it without any change in the treatment. Perhaps he caught 
it by imitation of some other patient in the ward, but the clerk 
has made no note of the fact. If so, both the supervention of 
the malady and its cure are easiest explained. 

Valerian is sometimes useful in chorea which arises in girls 
about and soon after the time of puberty, when it is apt to 
assume a paroxysmal form. This paroxysmal form we observed 
in Emma B., but still the valerian did not cure her. 

In all forms, however, you have seen a very decided improve- 
ment under the use of arsenic. 

I should not have called upon you to notice this, had they been 
recent cases, or if they had been cases in which a turn toward 
recovery had already been taken. Under such circumstances you 
may easily deceive yourselves as to the action of medicines, which 
do not cause, but are merely given along with the cure. About 
arsenic, however, I do not think you can have any doubt, ob- 
serving these and similar patients, that it really acts as a special 
tonic to the nervous system, — curing the chorea irrespectively 
of the cause whence it has originated. As arsenic is not a 
normal constituent of any part of the body, and cannot be 
imagined'to replace any normal constituent; while at the same 
time patients increase in strength and weight during the course 



CHOREA. 401 

of taking it, I suppose it must be an indirect constructive, acting 
powerfully on the nervous system. 



{Clinical, St. Mary's, June 13, 1863.) 

Of the three patients about whom I lectured a fortnight ago, 
Maria S. has gone home well, Emma B. is at work washing up 
cups and saucers, and Richard B. has improved as to his arms 
and legs, being able to walk straight and hold out an inkstand 
for me to write prescriptions from. But his organs of speech 
have not improved at all. He stammers, and chews, and gnashes 
his teeth most painfully, whenever he struggles to talk. 

Impediments to articulation are usually the most difficult part 
of chorea to cure. Many who have had chorea only in child- 
hood will stammer all their lives. So delicate are the muscular 
motions required for the rapid modifications of form which make 
the sounds of the different letters in speaking, and so decided 
and firm must they be for intelligible enunciation, that the 
slightest deficiency becomes immediately apparent. A muscular 
contraction which might be well enough directed to guide the 
fingers in writing, may be very incompetent to shape tongue and 
lips in pronouncing. A tremor not noticed in the former is dis- 
agreeably prominent in the latter. 

The annoyance to the patient caused by this difficulty still 
further increases it, so that it reproduces itself and becomes 
chronic. More than that, the glottis is irregularly acted upon 
and closed when it ought to be opened, so that speech, and some- 
times the breath is absolutely arrested. Nobody stammers in 
singing, when the glottis is kept open to form the musical tone. 

Stuttering and stammering are in fact a local chorea. There 
is a deficiency of voluntary control over the muscles of speech. 

In a recent case, such as this, very likely the arsenic will be 
of use, but I do not know whether it would be available where 
the defect has become habitual. The best way under that cir- 
cumstance is for the person to humble himself to the infant state, 
and be taught to speak all over again. He can get instruction 
from those ingenious tutors who teach the deaf and dumb, and 



402 CHOREA. 

systematically learn to shape slowly and deliberately his mouth 
into the form requisite for enunciating each letter separately. 
By practicing this at his leisure and before a looking-glass he 
may gain great control over the articulating muscles. 

I shall in this case continue the arsenic, and not recede from 
the large dose (Wjxvi of the liquor potassse arsenitis) unless there 
is perceived some poisonous action, such as sore throat, inflam- 
mation of the eyes, severe griping. I have also directed him to 
practice the reciting before a mirror sundry choice scraps of lit- 
erature relating to Peter Piper and his practices, which are pop- 
ular practice in p's. 

[This boy improved slowly, the arsenic having been increased up to TT^xviii 
of the Fowler's solution three times a day. He went out cured and able to go 
to work on July 3.] 

I have begun arsenic with another patient taken in yesterday, 
June 12, Ann W., whose case presents some analogy to the 
present condition of this boy, in that the chorea is confined 
almost entirely to one part. 

The said Ann W., a fine tall girl of thirteen only, though she 
looks older, has been subject to occasional chorea since she was 
five years of age. Latterly she has had an attack annually, and 
last year two attacks. The chorea is almost always confined, as 
now, to one arm; with one exception to the left arm. But once 
she had it in the right arm only, and last year in the left leg and 
left arm only. The catamenia have not yet been established. 
There is no abnormal murmur in the heart, and she has never 
been subject to rheumatism in any form. I have ordered her 
arsenic and shower-baths. 

It will be interesting to watch this case, and see whether the 
very local chorea is benefited by arsenic as decidedly as the 
more general chorea. 

[The dose of liquor potassse arsenitis was gradually increased to Tt^xiv. The 
patient was able to wash up crockery after she had been in hospital ten days, 
and was discharged on July 3. 

For three days I tried the experiment of controlling the spasmodic movements 
by fastening the affected arm against the side. The effect was to make it de- 
cidedly much worse. This observation is quite in accordance with the theory I 
hazarded in an earlier part of this lecture, that the voluntary nervous force is 



CHOREA. 403 

in chorea deficient from want of use, and that the exercise of the directing will 
is an important element in the cure. For that which is cured by the exercise of 
voluntary effort you would expect to be made worse by forcible involuntary con- 
trol, and vice versa.'] 



Part III. — [Continuation of same lecture.) 

I must not let you suppose, from the usually fortunate result 
of chorea under treatment, of which you are sure to see repeated 
examples, that a favorable prognosis can be always given as a 
matter of course. It is true that during the time in which you, 
my present class, have been pupils, .there have been no deaths 
among my patients so affected, nor indeed any discharged as 
incurable. But in my case-books there are several of both sad 
sorts, and I will briefly extract them, to damp any too cheerful 
ideas you might have acquired about the disease. 

John D. (No. in Reg. 442), aged sixteen, was transferred to me 
from Mr. Coulson February 13, 1852. He had been operated 
upon for stricture by the perineal section, and had accidentally 
been placed in a bed opposite to one occupied by a boy with 
chorea. He soon began to imitate the choreic movements of his 
neighbor, and though removed to another ward he got worse and 
worse, and lost all control over his limbs. When transferred he 
was found to have pericarditis, but the time of its supervention 
had not been noticed. He continued to get worse and worse, 
abrasions and sloughs and abscesses formed in various external 
parts, and he died delirious February 28. It impossible that the 
pericarditis and abscesses may have been due to pyaemia. 

Sophia G. (No. in Keg. 5003), aged eighteen, came to St. 
Mary's on June 15, 1855, with debility and pericarditis. The 
only illness she was aware of having had w^as chorea at four years 
old, which had not since recurred. Her pericarditis relapsed and 
got worse, and the chorea, so long absent, returned again. She 
died worn out with chorea and dyspnoea on July 21. 

Hannah M. (No. in Reg. 746), a needlewoman, aged twenty- 
three, was admitted November 1, 1861. Her sister told me she 
had been deserted by a lover the previous year, and Sad grad- 
ually faded away ever since. Her skin had got brown and harsh, 



404 CHOREA. 

her. body emaciated, and her mind sluggish. Then she became 
feverish, and a fortnight before admission exhibited the usual 
symptoms of chorea. These were then so bad that she could 
hardly be kept on the bed. No remedies were of any avail, she 
grew delirious, and then raving, and then comatose, and died on 
the 9th. At the autopsy we found (first), some old dry tubercles 
in the lungs and mesentery, dating probably from her first pining ; 
(secondly), degenerated supra-renal capsules, connected, it may 
be presumed, with the bronze-tinted skin; (thirdly), a scrofulous 
tumor as big as a filbert in the lumbar enlargement of the spinal 
cord, which probably was recent, and was the cause of the recent 
chorea. 

Two other cases were not fatal, but were not at all benefited 
by anything they received from the hospital. 

Sarah C. (No. in Reg. 24), aged twenty-three, married and 
full six months pregnant for the first time, was attacked on June 
20, 1851, with acute rheumatism of left elbow and right foot, 
and at the same time her right arm became affected with chorea. 
She was free from pericarditis on her admission, June 27, but got 
it on the morrow. Her rheumatic and cardiac symptoms sub- 
sided, but the chorea was as bad as ever when she went out on 
July 21. It continued till her child was born, two months after- 
ward, and then was cured. Had this young woman been in any 
danger, it would have been worth while to have induced prema- 
ture labor, but I do not suppose anything else would have stopped 
the chorea. • 

Robert F. (No. in Reg. 804), aged eighteen, son of a medical 
man, was transferred here from a madhouse, Nov. 30, 1860. He 
had practiced masturbation from the age of seven, but does not 
appear to have suffered in his health till he was sixteen, when he 
became affected with chorea for six weeks. He then remained 
well till the end of 1859, when the disease was brought back 
again by the same filthy practice I have spoken of. It was of a 
peculiar description, coming on in paroxysms, principally affect- 
ing the muscles of the neck, and twisting his head so far round 
sometimes as to cause him to tumble down, screaming and bark- 
ing. He had been in a lunatic asylum, for which of course he 



CHOREA. 405 

was not a fit patient, and had had subcutaneous injections of 
morphia at St. George's Hospital without benefit. Morphia was 
also tried here without permanent benefit, and also cauterization 
of the urethra. He was discharged incurable after a month's 
trial of various expedients. 

So jou see chorea is not always a disease of so little moment 
as appears from the bulk of cases, and perhaps from all the cases 
you may happen to witness during your novitiate. 

I will also use the hospital records to point out to you a curious 
fact in the history of chorea, which happens to be illustrated by 
none of the four patients at present under your eyes, nor in truth 
by any admitted under my care this session. I mean the con- 
nection between it and acute rheumatism. Out of thirty-three 
cases which I have looked over in my old case-books, in the fol- 
lowing six the nervous affection either began during rheumatic 
fever, or followed immediately after it before convalescence was 
complete, or else rheumatic fever succeeded to the chorea. 

Sarah C. (No. in Reg. 24), aged eighteen, mentioned just now 
as an instance of the chorea being unaffected by remedies, had 
both ailments at the same time, but without cardiac lesion. 

John J. (No. in Reg. 291), aged sixteen, had chorea imme- 
diately after rheumatic fever, but was also infested with intes- 
tinal worms. There was no cardiac lesion. 

Sophia G. (No. in Reg. 5003), aged eighteen, died of peri- 
carditis, very probably rheumatic, and chorea.' I have mentioned 
this case before among the fatal ones. 

Sophia M. (No. in Reg. 6425), aged seventeen, had chorea 
come on in the hospital during an attack of acute rheumatism, 
free from any cardiac complication. 

Eliza B. (No. in Reg. 6437), aged seventeen, had chorea come 
on in the hospital during an attack of rheumatic fever, but she 
had no recent affection of the heart detected then. When again 
admitted for chorea in the succeeding year, there was a soft 
murmur, systolic and probably anaemic. 

Martha C. (No. in Reg. for 1861, 346), aged twelve, was 
admitted with chorea. She denied having had rheumatic fever, 
though she said she had had rheumatic pains. The heart was 



406 CHOREA. 

healthy. • Next year she was under Dr. Sibson's care for rheu- 
matic fever, and then again the heart was examined and found 
healthy. 

You will observe, that though the association with rheumatism 
is evident, there is none made out with previous lesion of the 
heart; for, though Sophia G. had pericarditis, yet the others 
had no cardiac affection. Considering how very common inflam- 
mation of the central organ of circulation is in rheumatic chil- 
dren,* and that it is at this age that chorea usually occurs, on 
the mere doctrine of chances they would often coincide ; but the 
cases I have last referred to show that the constitutional con- 
nection is. really with rheumatism, and not with the valvular or 
pericardial injury. 

Indeed, when you come to consider that the red contractile 
tissue in the majority of cases of acute rheumatism is seriously 
affected in its functions, and in some cases (muscular rheumatism) 
is the only tissue affected, and that chorea is manifested by a 
want of control of the muscular nerves over the muscles, a con- 
siderable light is thrown upon the relation of two diseases at first 
sight so dissimilar. They are defects of vital f auction in the same 
part. In one case the sensitive, in the other the motor function 
is injured. 

I am sorry to say no practical assistance in their cure has been 
afforded by the observation of the connection between the two 
diseases. I have, in a few cases, applied to chorea the same treat- 
ment I should have applied to rheumatism, namely, warmth and 
alkalies, and it seemed to me rather injurious than beneficial. 
But the inverse inference I have not acted upon, and I do not 
know but what arsenic might be of use in rheumatism, and should 
be glad to hear of the experiment being tried. *f 

* It is dependent partly on the natural activity and excitability of muscular 
fiber in young persons, partly on their intolerance of pain and warmth, and the 
difficulty of keeping them from throwing off the bedclothes, and exposing their 
chest to cold air. 

f One such experiment, a decided failure, is recorded at the end of Lecture 
XVI, page 201, where a boy taking arsenic for chorea connected with old valvu- 
lar lesion, and of rheumatic diathesis, was attacked by fatal pericarditis, pre- 
sumed to be of rheumatic type. January, 1864. 



LECTURE XXXI. 

EPILEPSY. 

Cases illustrative of the use of iodide or bromide of potassium — 
Suggested explanation of the benefit so derived — Accessory 
treatment. 

(Clinical, St. Marys, June 20, 1863.) 

The following are the cases of epilepsy which have been in the 
hospital under my care since January 1. 

Richard L., aged forty-four, a married groom, had never any 
serious illness before February 20. On that day, soon after 
going to his work at seven in the morning, he felt giddy, and in 
two or three minutes afterward he became insensible and fell on 
the stable floor in a fit, during which, his companions told him, 
he was convulsed. A similar fit occurred the night after, and a 
third the next day. This was followed by a succession of fits for 
twelve hours, with intervals of from four minutes to a quarter of 
an hour. After that he had about three fits during each day. 
But during the nights they were more frequent, coming on when- 
ever he tried to go to sleep. On the 27th of February he applied 
for admission, and had an epileptic attack in our board-room. 
This one was seen to last about five minutes, being accompanied 
by casting up and twitching of the eyes and slight convulsions. 
His urine was natural, the genital organs normal in function, 
and no blow on the head or any other possible cause for the fits 
detected. He had the air of a sober respectable man. 

He was immediately put upon the following treatment : 



408 EPILEPSY. 

^ Potassii iodidi, gr. iv, 

Tincturse cantharidum, H\xv, 
Mist, camphor w, Sj, 

ter die. 
A small blister of an inch circumference behind each ear. 

The fits never recurred, and he entirely lost the feeling of 
giddiness and general malaise which had been experienced dur- 
ing their continuance. As his home was in the neighborhood, he 
was discharged as cured on March 6, with a determination to 
come back if he felt any likelihood of a relapse, to guard against 
which he was provided with medicine for a fortnight. [He has 
not since made his appearance. February, 1864.] 

A. M., a boy of twelve, had a cut on the head by a fall in 
fighting at ten years old. After it had healed he was quite well 
till last November. At that date he began to have epileptic fits. 
At first they resembled fainting fits, and occurred with various 
frequency, sometimes as often as seven or eight times a day. 
Since then they have become of a convulsive character and have 
occurred mostly at night. When they are coming on it seems to 
him as if the room were on fire ; this is succeeded by sudden 
darkness, and he knows no more. His mother states that he 
almost always goes to sleep immediately after the fits. His ap- 
pearance is healthy, and there are no worms to be found in his 
stools, though his mother had given him strong purgatives and 
carefully examined the results. There was ordered for him on 
March 20 the following prescription : 

Jty Potassii iodidi, gr. iv, 

Tincturse cantharidum, TT|v, 
Mist, camphor as, §j\ 

ter die. 

Up to March 25 he had a fit each day. His eyes were fixed, 
and the pupils much contracted during them, and he fell down, 
but did not bite his tongue. 

On April 1 he had at dinner time a short fit, and after that 
no more. He was discharged cured on the 11th, having taken 
no remedies beyond that named and two doses of castor oil. 



EPILEPSY. 409 

Eliza D., an unmarried nurse-maid, twenty-four years of age, 
was admitted by governor's order, May 1, for epilepsy. She 
had her first fit sixteen months previously, when she was at the 
Cape with her mistress. At first she was not completely in- 
sensible during the fits, and had no convulsions, but soon they 
took on a more decided epileptic character, and latterly they 
have come on more frequently, sometimes as often as two or 
three times a day. The catamenia have never been quite regular 
to time, but otherwise she has been a healthy woman, except for 
the epilepsy. She is spare, brown, and intelligent, without any 
signs of hysteria. She was^put upon the treatment by 

1^ Potassii hromidi, gr. xv, 
Mist, camphor w, §j, 

ter die. 

During the night of the 5th she had two epileptic fits in 
which she bit her tongue. The bromide of potassium was in- 
creased to gr. xx, and she had no more fits. 

Thomas K., a G. W. R. porter, was admitted on April 11 
during an epileptic fit, which he had in going to his work at four 
in the morning. He was treated with a turpentine enema and 
a blister at the back of neck, but as he did not wish to be kept 
from his work I lost sight of him. 

I bring to your notice these four last cases of epilepsy which 
have been under my care in the hospital, because in most of 
them a similar remedy has been used with apparently great suc- 
cess. Two have taken the iodide and one the bromide of po- 
tassium, and it certainly seems to have controlled the disease in 
an extraordinary way. 

Remark that all these three epilepsies are comparatively 
recent. I have, as a rule, refused to admit long-standing cases, 
as causing a great deal of trouble and expending in vain the 
funds of the hospital. And I think that trials of all remedies 
should be made on recent cases, for confirmed epilepsy has be- 
come such a habit in the syetem that it may be looked upon as 
incurable. Even there iodide and bromide of potassium will 
27 



410 EPILEPSY. 

alleviate the evil. In one case due to an old saber cut on the 
skull so long ago as the Greek war of independence, and accom- 
panied by partial paralysis, I gave, in consultation with Dr. 
Watson, iodide of potassium, and the fits became not only less 
frequent but milder. Another case of fourteen years' duration . 
and used to recur every three weeks, has now been nearly six 
months without a fit under the use of fifteen grains of bromide 
of potassium three times a day. 

This latter case had tried to take the iodide, but even in small 
doses it so soon produced its poisonous effects, sore-throat, irri- 
tative fever, &c, that it was never fairly tested. 

Sometimes we fail. I gave the iodide last winter to a young 
clergyman for epilepsy of not above a year's duration. During 
three weeks' stay in London he was indeed free from fits, but on 
returning home they recurred as bad as ever. Singularly 
enough I had a few years before given this man large doses of 
iodide of potassium for non-syphilitic periosteal rheumatism, and 
it had acted like a charm. Is it possible that the drug can have 
lost its effect over one disease by having been previously used 
for another in the same patient ? At all events he left it off, 
and when I last heard, he was taking, under advice, mercurial 
alteratives to act on the liver and so on, not apparently with 
any advantage. 

This class of neutral salts seem to have a peculiar restorative 
action over the white fibrous tissues. They were first brought 
under the notice of the profession by the effect of iodine* in 
scrofulous diseases of the glands, and then by their cure of 
syphilitic periostitis. A notion got into the profession that they 
had some antagonistic, or controlling, or evacuating power over 
syphilitic virus ; but the more recent surgical writers, such as 
Mr. Lee, think there is evidence against that idea, and that they 
benefit by curing the diseases arising out of the presence of the 
virus and not by removing the virus itself. They cure the pa- 
tient's tissues, without specially affecting the materies morbi, if 
we may apply that misused term to the poison which is the 
foreign cause of disease. You may see proof of this opinion in 
the fact of the equal benefit which they confer in rheumatic and 



EPILEPSY. 411 

other non-venereal cases of periosteal disease. When recently 
affected, these patients are restored to health as readily as the 
subjects of secondary syphilis; and the apparent resistance in 
some cases to the remedy is due to the protracted nature of the 
ailments ; just as syphilitic periostitis, when it has lasted a 
long time without medical aid, is very obstinate also. On the 
ground that iodide -of potassium has a special restorative power 
over the white fibrous tissues, I should expect most direct benefit 
from it in epilepsy to those cases where epilepsy is due to some 
lesion of the membranes of the cerebral or other masses of nerve 
substance, whether that lesion be temporary or permanent. 

But at the same time I have no data by which to doubt of its 
curative influence, where the disease arises from lesed nutrition 
or visible tumors of nervous matter. It may not improbably 
restore also that tissue to healthy vitality. 

Neither should I be disposed to be skeptical of its virtue where 
a peripheral cause exists for the convulsions. That peripheral 
cause may be an altered state of some fibrous tissue, and it can 
hardly act otherwise than through an altered nutrition of the 
nerve or its envelopes. 

It is also something to say that no permanent injury to health, 
and scarcely any even temporary inconvenience is ever wrought 
by iodide of potassium. Some persons, misled by an accidental 
instance or two of lunatics having previous to their lunacy taken 
this drug, have disseminated the notion that it weakens the 
mental powers. At the Lock Hospital for syphilis we administer 
annually some hundredweights of it, but have never found such 
a result follow. So that there are no patients affected with 
epilepsy on whom we are justified in not fairly trying the experi- 
ment of its use. 

I need hardly tell you how important hygiene is in the treat- 
ment of epilepsy. The measures most to be insisted upon are 
those specially connected with the etiology of the disease in the 
particular case. Should mental causes, such as fright, anxiety, 
disappointment, lie at the bottom of the evil, a complete change 
of habits must be enforced ; and that is easiest carried out by a 
complete change of residence and of companions. The same 



412 EPILEPSY. 

expedient will also powerfully aid dietetic improvements in 
instances where the digestive tract is at fault. In such cases a 
mild soluble animal dietary which feeds the tissues by frequent 
nourishment, without overloading the stomach by copious meals, 
such as the diets of our hospitals, is of the greatest value — of 
such value indeed, that some even hesitate to accept hospital 
experience of drugs in this disease as conclusive of their real 
action. All ambitious intellectual exertion, especially rapid and 
discursive reading and writing against time, should be absolutely 
prohibited. But moderate employment of the thoughts, espe- 
cially on familiar and interesting hobbies, is useful in preventing 
that stagnation or concentration of the mind upon itself which 
is so hurtful in all chronic complaints. 



LECTURE XXXII. 
HYSTERIA. 

Part I. — Hysteria not fatal, but not therefore unimportant — Not 
a uterine disorder — Its pathology lies betiveen mind and 
body — Its forms to be divided according as it approaches one 
or the other — Such a division has a direct bearing on the 
treatment — Mental hysteria — Treatment, restoration of vol- 
untary mental force, of cutaneous circulation, and of 
emotional control — Corporeal cause for hysteria — Treat- 
ment, tonic to mucous membranes — Effects of tea-drinking — 
Treatment dietetic. 

Part II.— -Hysterical vomiting — Three cases in hospital compared 
with some private patients — It is not in strictness vomiting — 
Diagnosis and treatment — Their difficulties — Hysterical 
cough — Contagiousness of hysteria. 

Part III. — Connection between hysteria and insanity illustrated 
— Medical curiosity about private history of patients — A 
physician not a confessor. 

Part IV. — Periods of life prone to hysteria — Blighted affections, 
lowering diseases, and climate, as causes — Two cases of 
hysterical loss of voice treated by valerian and shower-baths 
— Spasmodic cough and spitting of blood in one patient — 
Advantages of auscultation in the diagnosis of the latter. 

Part V. — Treatment by ice — Treatment by blood-letting — Gen- 
eral conclusions. 

Part I. — (Clinical, St. Mary's, November 8, 1861.) 

Those who rate the importance of diseases solely by the space 
they fill up in the Registrar-General's report of deaths, will 



414 HYSTERIA. 

care very little about the subject of the present lecture. Hysteria 
does not show its face at all in that book. The reason is, that 
whenever it leads to a fatal result, it qualifies itself to be classed 
either as insanity, epilepsy, or some organic lesion ; and thus our 
pathological friends who pay attention only to what people die 
of, are apt to ignore it altogether. But this is not a practical 
way of viewing the human misery you are learning to lighten. 
The sum total of suffering from hysteria to patients and their 
friends is very great, and probably equal to that included under 
most of the names followed by high numbers in the lists of 
mortality. 

The chief thing that should make disease interesting to you is 
the amount of misery which it inflicts, and the likelihood there 
is of your exertions alleviating this misery ; not the gratification 
of your vanity by observing how the phenomena during life are 
explained by the post-mortem appearances. I hope you will not 
be led by the excellent opportunities for the study of morbid 
anatomy w T hich student life affords to rate that science as the 
only glass through which you should look at disease. . It is very 
rarely anything which can be put up in a bottle or made into an 
interesting preparation or picture, that patients feel, and that it 
is the business of your life to help them to feel less. The true 
use of morbid anatomy is to teach the consequences of disease, 
not the art of healing it, and it is the art of healing which must 
be the prime object of your work in the hospital wards, and the 
business of your lives. You must not get a habit of classifying 
ailments according to parts affected only, or a great many will 
escape altogether from your nosology, and some you will not be- 
lieve in at all perhaps. Of others, again, the names will give 
you altogether wrong notions ; and of these hysteria is an 
instance. 

It is seldom I ask you to erase anything from your memory, 
but — will you please to try and forget for the nonce that hysteria 
is derived from the Greek word 'varepa ?* That is the readiest way 

* Hysteria with the second syllable long, as usually pronounced, means " a 
festival at which swine were immolated" (Donnegan), but I suspect the original 
designers intended the e to be short. 



HYSTERIA. 415 

of avoiding the trap which the name sets open for the educated 
student. In reality it has no more to do with the organ of repro- 
duction than it has with any other part of the female body ; and 
it is no truer to say that women are hysterical because they have 
wombs, than that men are gouty because they have beards. You 
may see daily in the ward appropriated to uterine cases all sorts 
of pathological changes of the part in question, without any 
greater tendency to hysteria than in other women ; and on the 
other hand, hysterical women are all around you, among both in 
and out patients, whose uterine functions are perfectly healthy. 
Of two women I have examined who were born without any 
uterus at all, one was hysterical. 

Our forefathers, who invented the term still used, seem to 
have fallen in with a popular notion that the womb really danced 
about into all the strange places where discomfort is felt. They 
allowed their patients to think of that mysterious organ as now 
starting up under the left ribs and causing lumps and pain in 
the side, and properly enough therefore called "spleen" by 
classical writers of the Addisonian period, now jumping right up 
into the throat as a "globus," and now intruding itself into 
the brain, appearing like a nail driven in — a " clavus" — over the 
brow and disturbing the senses and passions. You may easily 
conceive that the believers in such superstitions were not trust- 
worthy practitioners ; but you will be equally bad if you fall 
into the error of treating hysteria as a disease originating in the 
womb. 

Observe impartially the phenomena in those cases which come 
before you, and you will not fail to be convinced that the deficient 
vitality of which hysteria is a manifestation is in that puzzling 
part of the circle of life which lies between spirit and matter. 
We know so little about the chain which connects the two, that 
its links are reckoned by us as few and short, and we have no 
names for any of them. Yet when we see the varied phenomena 
produced by breaches or impediments to the connection, we are 
led to feel the depth of our ignorance on the subject, and to con- 
jecture that these abysses of incertitude veil a long list of vital 
functions. 



416 HYSTERIA. 

In default of names for even the healthy functions of this part 
of life, we must not expect an accurate nomenclature for their 
aberrations from health ; and the most we can do in trying to 
classify forms of hysteria, is to trace how near their origin lies 
to one or the other extremity of the series of vital actions which 
are interfered with ; what relation their phenomena bear on the 
one hand to mind, and what on the other to body. We shall 
thus have set in a natural series the varieties of the disease, with 
pure insanity at the one end, and epilepsy traceable to organic 
lesion at the other. Such a nosology has a directly useful bear- 
ing on our treatment of the patient, which I cannot affirm of any 
other attempt at classification of hysteria that I have yet seen. 
I say it has a direct bearing on our treatment of the patient to 
observe in each individual case whether the disease is most re- 
lated to deviation from mental or bodily health ; for I feel con- 
vinced that it is only by this observation that we can avoid such 
disappointment as leads many in our profession to look upon 
hysteria as an opprobrium medicinde, which makes them feel the 
same sort of anger against it that is roused by moral guiltiness, 
and disposes them rather to punish than to cure the patient who 
has thwarted them. 

After this unusually long introduction I proceed to the busi- 
ness of the day, by calling your attention to three cases we have 
visited during the last week in the larger female ward. 

The first couch we come to is tenanted by E. J., a nursery- 
maid aged seventeen, who was brought here from her bed in her 
night-dress and wrapped up in blankets, as an " urgency" during 
the week. She complained of dreadful pain and absolute loss of 
power in the legs, so as to be quite incapable of standing. She 
said that five days previously her legs had been red and swollen, 
and that they had been rolled up in " bandages twenty yards in 
length;" though in the same breath she declared that they were 
so painful that she could not bear them to be handled, and that 
it made her faint to have them touched. This illness she at- 
tributed to having caught cold, accompanied by diarrhoea, when 
with her mistress at the seaside, whence she has just come back. 
She complained also of stiffness and severe pain in the muscles 



HYSTERIA. 417 

of the neck and of pain in the heart, and of excessive perspira- 
tions. In short, she gave a fair description of the symptoms of 
an attack of rheumatic fever, and in truth she was sent to bed 
as a case of rheumatic fever, and so entered in the " Urgency 
admission book." But my eyesight did not let me concur in this 
diagnosis. The legs and feet were evenly smooth and white, and 
she did not cry out when any part was handled except the calves, 
to which she said the pain .had retreated. Now the pain of rheu- 
matic fever retreats to the joints, and not to the calves. More- 
over, there was no swelling of the neck which she said was so 
painful ; and, on diverting her attention, the cardiac region bore 
pressure without her flinching. And the flushing of her face 
seemed not due to fever, but rather to mental excitement. Then 
we noticed that the inside of her lips and her tongue were pale, 
and that the latter was indented by the teeth ; while there was 
a soft, soughing murmur, such as you find in anaemic persons, 
synchronous with the first sound of the heart. But what mainly 
led me to the diagnosis which I formed of hysteria was the ex- 
pression of her countenance. She has an easily flushed skin, 
delicate features, quickly answering to the movements of the 
mind, and in the eyes a peculiar appearance which requires a 
separate sentence to itself. The balls are large, and the sclerotic 
of a transparent sky-blue ; the pupil is much dilated, giving a 
general dark hue to a naturally light eye, and the conjunctiva is 
smooth and bright from being overspread with tears on every 
emotion. The eyelids are large, full toward the outer canthus, 
giving a drooping, appealing expression to the face. I believe 
this is what ladies technically call u a sweet expression." Of 
these several hysterical marks, the puffiness of the eyelid and the 
dilatation of the pupil are the most constant — indeed are seldom 
absent — and seldom deceive you. 

Her history has oozed out in driblets during the four days she 
has been here, and has been made up partly by a motherly old 
woman in the next bed; for it excites her too much to attempt 
much cross-questioning. I would commend to your imitation 
this mode of piecing up a history by what can be extracted from 
the patient by those who can listen at leisure. Excitable per- 



418 HYSTERIA. 

sons are prone to exaggerate, to invent, to forget, and to appear 
to you impostors when cross-questioned by a stranger. 

It seems that E. J. has been in service since she was twelve 
years old, and enjoyed capital health till sixteen months ago, 
when she had a sad shock. She went home for a holiday, having 
heard of no illness in her family, and found her father in his 
coffin. This completely upset her. She has shifted about from 
service to service, and has always been obliged to leave from in- 
ability to get through her duties. The first bodily symptoms she 
perceived were languor and a palpitation of the heart on exer- 
tion; then she became subject to "fits," as she calls them; if any- 
body made her laugh, she could not stop, soon began to cry and 
to scream, and fell into very low spirits afterward. During this 
period the catamenia flowed for the first time last December, and 
appeared again in January: she says that she was neither better 
nor worse for the change of constitution. Since January they 
have been absent. 

This is a case of hysteria arising from a distinctly mental 
cause, and showing itself in mental symptoms. The organs first 
affected are those which are especially obedient to the emotions 
of both pain and pleasure. First the heart, then the risory, lach- 
rymatory, and expiratory muscles. In health, we know how these 
are affected by changes in the mind, but are still under its con- 
trol. When then we find in a patient that control deficient, and 
when we can trace the deficiency to a cause purely mental, it is 
rational to conclude that the broken link is nearer to mind than 
to matter, and it is rational to let this conclusion govern us in 
our treatment. 

I would here again warn you, as I did at the beginning of the 
lecture, against associating hysteria with the reproductive organs 
or functions. To read some male authors on this subject one 
would suppose that it was only a euphemism for lust. A signal 
injustice is thus done to the weaker sex, and they might well 
ask, as iEsop's lion did of the natural historian, if women wrote 
books on the diseases of men how would the creatures be de- 
scribed ? If you study in an unprejudiced spirit the histories 
of the numerous cases of hysteria which fall under your notice 



HYSTERIA. 419 

you will learn that the sexual instincts are not oftener the moral 
cause of the disease than any other social circumstances, and 
that physically the differential organs are less frequently at fault 
than any of the important viscera. Neither are lustful desires 
the consequence of hysteria any more than they are the conse- 
quence of all that weakens the mental powers, of all that lowers 
our species in the scale of creation and brings us nearer to other 
animals. Emotional hysteria is a primary disease of the mind as 
much as lunacy is. 

As in lunacy, so also in hysteria, there follow morbid phenom- 
ena connected with the manufacturing viscera. The stomach 
loses its power of digesting food enough to supply the waste, and 
the person becomes anaemic. Then the destructive metamor- 
phosis is checked too, the urea is excreted in diminishing quan- 
tities, and the unrenewed blood supplies no coloring matter, so 
that the urine is pale and watery. In short, the patient becomes 
anaemic ; and with anaemia, of course, there is a deficiency in the 
sanguineous excretions especially. Thus in this girl, as you have 
.heard, puberty truly began in spite of the illness ; but power was 
wanting to carry on its periodical evacuation of effete blood. The 
catamenia flow T ed twice, and then ceased. Next to the stomach 
probably ranks the uterus in its liability to be affected by the 
mind — a fright may suspend the catamenia or' cause miscarriage 
in a perfectly healthy woman ; and in female lunatics the courses 
are scarcely ever regular — so that it is quite in accord with anal- 
ogy that the same defect should occur in the half-mental affec- 
tions which we reckon as hysterical. 

Next notice the treatment. 

First. She was taken into the hospital as an in-patient. You 
will find in practice that however good your theory of the treat- 
ment of hysteria may be, it is much more difficult to carry out 
and much less effective when the patients are at home than 
when you can remove them for a time from their ordinary habits 
and associations. It is not merely that unprofessional nurses fail 
to obey implicitly your orders, from misplaced tenderness or ig- 
norance ; but that the patient's mind, by running in its habitual 
groove, and being perpetually subjected perhaps to the influences 



420 HYSTERIA. 

which engendered the disease, less readily takes a turn toward 
health. If you expect in private practice to be as successful as 
hospital physicians, you must try to imitate the circumstances 
they have in their favor. This is most easy in the poorest and 
in the richest classes. The first can be sent into a hospital; 
and with the latter a thorough change of scene, under the charge 
of some judicious friend, is not difficult to arrange. But this is 
often next to impossible for the families of farmers, retail shop- 
keepers, curates, village doctors, and the like, from the union of 
a light purse with a weighty feeling of independence. One good 
plan that can sometimes be adopted, to the saving of pride and 
pocket together, is to negotiate an exchange of patients, where 
two families of about the same social standing are simultaneously 
afflicted with an hysterical member. The relatives of A can take 
charge of B, and the friends of B repay the debt by their care 
of A. Mere kindness even may induce people to receive on a 
visit such inmates, if it is pointed out how very valuable the 
kindness really is, what a high office of Christian charity is thus 
fulfilled, when a sick person, incurable at home, is rendered 
curable by removal. 

In the wealthier classes the complete renewal of mental asso- 
ciations involved in foreign travel is a mighty engine of cure. 
But yet if an hysterical patient be sent abroad during conva- 
lescence, you must not be quite careless where you send her to. 
Some places enjoy a bad pre-eminence for producing relapses. 
These are generally low-lying places of even temperature; and 
I suspect there is some connection between malaria and the in- 
duction of the disorder, Rome is an instance in point. I was 
much struck, when residing there a few years ago, by the fre- 
quency with which all disease was modified by hysterical phe- 
nomena And one case I saw of well-marked catalepsy, which 
strongly impressed me. It occurred in an English lady who 
never had hysteria before in any form, and who was excessively 
frightened by the unfamiliar symptoms. It came on within 
twelve hours of her arrival on a muggy spring evening, when 
she was fatigued by her journey, and open to all the injurious 
aerial influences of the Campagna Romana. During her stay 



HYSTERIA. • 421 

she was from time to time threatened with a recurrence, and 
feared she was a destined victim of nervous invalidism; but on 
leaving Rome the symptoms vanished, have never recurred, and 
were thus proved to be wholly due to the peculiar climate. Be 
careful that your hysterical patients keep clear of the Eternal 
City.* Much harm is often done by sending them to travel in 
Italy without a warning on this point. 

Whatever be the scheme adopted for securing a change in 
habitual trains of thought, the principle of treatment will be the 
same. You must aim at bringing back the control of the mind 
over the body. A link has been dropped, is becoming paralyzed 
for want of use, and must be renewed. Let the patients be 
exercised in voluntarily obeying specific orders for the direction 
of the will ; moving the limbs to time, at first slowly, and after- 
ward with more liveliness, till at last the culminating point of 
dancing can be arrived at. This is the crisis of the cure ; and 
when a girl can be induced to join a quadrille in the evening, you 
need not fear a relapse into hysterical paralysis. In the hospital 
we are obliged to substitute "dull mechanic pacings to and fro," 
assisting in the work of the ward, &c. ; but these are much bet- 
ter than nothing. The same strong effort requisite for these 
exertions is to be used to restrain the tendency to hysterical fits. 
The truth is to be forced upon the patient that she can learn to 
repress these manifestations of weakness ; and with the learning 
will come the power, and with the power the absence of 
occasions for exercising it. 

What you have to aim at is exactly the converse of the arts of 
the electro-biologist, mesmerist, and medium-showman. These 
persons, with devil-like ingenuity, find means to induce a form of 
artificial hysteria in subjects with a tendency to mental disease ; 
that is to say, they partially destroy the control which the mind 
has over the body, and subject it to the suggestions of their own 

* A reviewer of the second edition of this volume throws a doubt on this 
accusation against Rome. I was not aware that it was new; but if so, I am 
glad to find it confirmed by Dr. Scoresby Jackson in his recent excellent work 
" On Climatology." He describes the climate as productive of " a morbid nerv- 
ous sensibility;" and afterward advises that all cases "of perverted nervous 
sensibility" "should avoid Rome." 



422 * HYSTERIA. % 

will. Let it be your happier task to restore this control by in- 
ducing the patients to exercise it for themselves. Above all 
things, never be led by curiosity or idleness to repeat the ex- 
periments alluded to. Each time that poor creatures are so 
practiced upon, they become more and more enslaved to the 
morbid impressions, till they lapse into permanent hysteria or 
even insanity. You might just as well give a man pneumonia, 
or break his leg, for the purpose of studying the consequences. 

Secondly. Shower-baths were ordered to be given every morning. 
The making up the mind to the shock of a cold shower-bath, is a 
capital exercise of the will. In summer it is most suitable ; and 
I dare say you remember in July, 1860, a farmer's daughter 
whom our late house surgeon, Mr. Ash, sent up from Cornwall 
with absolute paraplegia of both legs. This case excited much 
amusement at the time, because it was attributed by the girl's 
neighbors to witchcraft. It was due to hysteria ; and she was 
ordered a shower-bath twice a day, with the effect of enabling her 
to walk one day to the Pantheon, and another round the Serpen- 
tine, before she went home cured. 

I say " cured," partly because I have lately heard from Mr. 
Ash of her really being so, and partly also because I should 
anticipate the best results from the slow progress of her improve- 
ment. It is sometimes possible by a strong mental emotion to 
overcome suddenly nervous paralysis. You have all, I dare say, 
read at school Herodotus' story of the dumb child of Croesus, 
who in a battle recovered his speech, and stayed the soldier's 
up-lifted sword by crying out "Spare my father." I know a 
case of permanent hysterical paralysis which was several times 
suddenly cured, once by the house catching fire, once by the 
patient's maid being struck down by cholera, once by an obsti- 
nate physician desiring her to rise up and walk. After each 
trial she was able to move about for a few days, but she relapsed 
again as bad as ever, and remained paralytic till her death from 
other causes. Gradual cures are indubitably the most trust- 
worthy. 

In winter a shower-bath twice a day would be rather a strong 
measure ; and it is better to prepare the patients for it by the 



HYSTERIA. v 423 

use of a tonic warm bath, such as the following, which you often 
see me order : 

^ Acidi TiydrocMorici diluti §iss, aquse calefactse ad 95° 
Fahr. congios xxx. M. Fiat balneum. 

Shower-baths have also a good influence by arterializing the 
cutaneous circulation. Their immediate effect is to drive the 
venous blood home to the heart and lungs ; and that which takes 
its place is arterial, as every one knows who has reflected on the 
pink cheerful glow of his person while drying himself after this 
morning luxury. 

Thirdly. Valerian was ordered to be taken three times a day. 
There are several substances dowered with a special action on 
those nervous functions which minister to the emotions. They 
come from different kingdoms of nature, and agree in no one 
point except in having all a very strong smell. The essential 
oils of sundry plants which are the pride and profit of the per- 
fumer, the rose, bergamotte, tuberose, violet, hyacintji, fresh hay, 
and some others of the few sweet scents that exist in the world, 
are poisons to all with a tendency to hysteria, and are proscribed 
by universal consent of fashion in aril places where the disease is 
endemic. In Rome, you would as soon think of going to an 
evening party with a drawn sword as with a strong-scented nose- 
gay, in any hope of its acceptance. Tea is equally baneful, and 
the bad effect seems to dwell rather in the essential oil than in 
the alkaloid which it holds ; for coffee, which is as rich in theine, 
is by no means so hurtful. On the other hand, the bracers-up 
of the nerves would seem to have this good gift in recompense 
for their peculiar offensiveness in their raw state to the healthy 
nose — valerian, assafoetida, garlic, castor, musk, and I believe 
some others whose disagreeable virtues are not familiar to me. 
The first two are the best ; as, though musk is very beneficial, 
its high price and the unbearable permanence of its odor render 
its use inexpedient. In hospital, you will generally see me ring 
the changes upon the following prescriptions : 

ly Tincturse Valerianae compositse 5j> Infusi Valerianae ad 5j. 
M. Fiat haustus ter vel quater die sumendus. 

Ify Assafoetidee gr. 'x in pilidis ter die sumenda. 



424 HYSTERIA. * 

ly SpiritHs ammoniae fostidse 5j ex aqud ter die sumendam. 

But in private practice more elegant substitutions can be made 
to suit the patient's fancy, such as — 

^ Tincturse castor ei ammoniatse (Pharm. Bub.) 5\j, aquee 
fceniculi ad oj ; 
or — 

3^ Pilulae galbani composite gr. x ; 
or — 

3^ Zinci valerianatis gr. iij ; 

One or other to be taken three times a day. 

You will remember, I hope, that drugs, whatsoever may be 
their powers, can never take the place of other treatment. They 
are merely an aid and a means by which the essential principles 
of restoration may be carried out ; but if they be trusted to 
empirically, if the disease be prescribed for and not the patient, 
failure will attend your best efforts, and a disappointed skepticism 
haunt you in or drive you out of our godlike occupation. 

The next case before us is an instance of hysteria exhibiting 
a more material ailment from a more material cause. 

Maria E., a muscular matron of forty-two, was confined of her 
eleventh child nine months ago, and had gone on letting it suck till 
the other day. Very little milk there was for it indeed; and 
the only use of the nipple must have been as a sort of opiate. 
Notwithstanding its difficulties, by dint of other food the baby 
has grown fit to be described as a "beautiful fat" one; but the 
mother has been severely punished for kicking against the pricks 
of instinct. Four months ago she was taken with a succession 
of fits, which drew her arms and legs up in convulsions, and took 
away her voice. She was sometimes quite paralytic, and some- 
times lost her senses, but never bit her tongue. Then she became 
afflicted with dyspnoea, which, even now as she lies in bed, cuts 
short her speech, and is constant when she is up. Her appetite 
is quite gone, so that she loathes the sight of food. She has also 
excessive pain in the left hypochonclrium, which often, in her 
own words, "quite doubles her up," but yet does not arise from 
flatulence. The catamenia have returned at their proper periods, 
in spite of the illness brought on by her too persevering attempt 
to suckle the child. 



HYSTERIA. 425 

You may see here again the hysterical eye, with large pupil, 
clear sclerotic, full upper eyelid, and look of appeal for sympathy. 
This time it occurs in a brunette, and in a woman whose face 
might have led you to guess her to be of a stern, strong-minded, 
or ascetic character. 

Now the treatment here is different from the last. She was 
ordered for medicine — 

3^ Tinct. cinchonse co. 5j? decocti cinchonse ad Sj- Fiat 
haustus ter die sumendus. 

She was kept quiet in bed, and bidden to take a cup of limed 
milk every two hours. I looked upon the chain of causation in 
this case as arising thus — (1) exhaustion ; (2) imperfect gastric 
digestion ; (3) anaemia ; (4) innutrition of nervous system, and 
the consequent exhibition of its weakness in hysterical phenom- 
ena. And I considered that the easiest channel by which to 
commence the renewal of life was the stomach. It would have 
been useless to load the poor organ with a quantity of heavy 
victuals, of which it could only have relieved itself by rejecting. 
But frequent small amounts are not beyond its powers ; and if 
you give these as medicine, the patients will not think themselves 
at liberty to choose or refuse, as they do food. Medicine indeed 
it is ; for it is intended to cure the stomach of its anaemic, inert 
condition, and thus to give an appetite. The cinchona is designed 
to have the same effect, by astringing the surface of the mucous 
membrane, checking its secretion of sticky mucus, and thus en- 
abling the gastric juice to reach the food. And you see that 
between them the effect is brought about ; for, as we went round 
to-day, the patient said her desire for food was coming back, and 
of her own accord asked for meat. The pain in the splenic region 
was much better, and the dyspnoea gone. 

Wondrous is the power of the stomach ! When in its right 
senses, what a restorative physician it is ! By the aid of our 
patients' stomachs alone we can cure nine-tenths of the curable 
cases of disease. Persius dubs it a " Master of Arts ;" I would 
give it the degree of " Doctor of Medicine." 

Another case of hysteria with a traceable bodily cause came 
to us on the same day. 
28 



426 HYSTERIA. 

Maria D., a spinster of thirty-two, has been a general servant 
in a light place for seven years. She has been happy, and has 
enjoyed pretty good health, interrupted only by occasional head- 
aches ; but for some time lately things have seemed to annoy 
her more than they ought to do. Three months ago she had a 
bad "bilious" headache, which was followed by some fits of 
laughing and crying. Five weeks ago she had an attack of di- 
arrhoea, from which she got better, and went to work again in 
spite of weakness, for she was loath to let her mistress want her. 
But her exertion was in vain, for she no sooner tried to clean a 
grate than she fell down speechless, and had a succession of 
hysterical fits, losing her senses, but not biting her tongue. Then 
she began vomiting everything she took, and this had been going 
on for three weeks, and seemed to amount to a complete rejection 
of all her food immediately it was swallowed. When you saw 
her, there was excessive flatulence, the air bursting up from the 
stomach in roaring eructations while one was talking to her. 

In this woman, the effect of the wide pupil and sympathetic 
hemiptosis is not hidden even by the disfigurement of blear 
edges to the eyelids ; and it quite accords with the droll earnest- 
ness of her manner, which increases gradually as you let her go 
on talking about herself, leaving no doubt of her strong hys- 
terical diathesis. 

As to cause, that is still more directly traceable to the stomach 
than even in the last case. It would seem that for some years 
she has been becoming more and more given to tea-drinking. 
She confesses to caring for little else, so long a.s she could get 
her favorite food or physic — or poison — I do not know exactly 
how to call it. Her mistress was quite angry with her for eating 
so little meat ; and, with a far-sighted economy not common in 
her class of life, took much trouble to keep up the health of a 
faithful servant. But her weakened stomach refused meat, and 
she was literally starving in the midst of abundance.* 

* This patient has just returned to the hospital. She has been well from the 
date of her discharge till a fortnight ago, when she sat up several nights, and 
was very anxious about her sick mistress. This has caused a return of hysterical 
vomiting. Feb. 1864. 



HYSTERIA. 427 

In this case diet will be the cure. When we can make our 
patient a carnivorous animal again, she will be well. But what 
is the use of diet or medicine when it is all thrown up ? None. 
With this feeling, at the same time (November 1) that I ordered 
her limed milk every two hours, I added also an enema of 
half a pint of mutton-broth four times a day. On the 5th, about 
half the liquid swallowed was retained, and she complained that 
the anus was made sore by the clyster-tube. The enema was 
therefore omitted, and the power of resisting nausea was aided 
by four minims of prussic acid every four hours. On the 7th 
she vomited scarcely at all, and said she would try and keep 
down a piece of meat. This she has continued to do, and may 
be now counted convalescent. 

Part 11.— {Clinical, St Marys, May 16, 1863.) 

I will call your attention to-day to a case of hysterical vomit- 
ing, namely, that of Hannah P., aged eighteen, who has been in 
the hospital a fortnight. She is a respectable farmer's daughter, 
and seems to have been much petted at home. She has large 
black pupils to the eyes, and puffy eyelids, and allows that be* 
fore her present illness she. used to have hysterical fits, but not 
since she has suffered from what she came here for, namely, 
chronic vomiting. I should rather call it a rejection of food, for 
it occurs immediately after food has been taken, almost before 
it is swallowed. This happens at every meal, and has lasted a 
year and a half, and during that time she has been for a short 
time in her county hospital with relief but not cure. She has 
also pains in the back and in the splenic region. She declared 
she was unable to walk or even to stand without assistance, and 
when placed upright in the middle of the room she fell down at 
first. Nevertheless, after a scolding and decided command to 
exert her will vigorously, she at last began to put one leg before 
the other, and progressed a few steps even on the first day. The 
catamenia had been absent three months, and indeed had never 
been established at regular periods. 

There is a peculiarity about hysterical paralysis which in a 



428 HYSTERIA. 

great many cases guides you to its nature — and guiding you to 
its nature is here more than anywhere a most important step in 
the cure. When you set the patient up on the floor, assisting 
her with one or two hands or with your hands under the axillae, 
according to the degree of paralysis and the amount of aid 
wanted, the body is immediately thrown forward, and all your 
strength is called for to prevent her falling on the face. Other 
paralytics fall to one side or the other, or backward, and do 
not stumble forward in this way. The peculiarity is well marked 
in the present instance, and has aided the diagnosis.* 

This is an example of that extremely troublesome disease 
"hysterical vomiting ;" by which I mean a vomiting of food 
independent of any organic or anatomical alteration of tissue, 
and due to mental or functional deficiency of the nervous power 
of control. The pathology of the disease seems to be this : 
when the food enters the oesophagus, the lower muscular fibers, 
being deprived of proper cerebral control, act too soon, and the 
upper muscular fibers are too soon relaxed, so that the morsel 
instead of being pressed downward into the stomach is returned 
back again to the mouth. Unlike other persons, the hysterical 
are unable to check by a strong voluntary effort the conversion 
of nausea into vomiting; and often, if they are able, they are 
unwilling to do so by reason of the peculiar perversion of their 
minds. 

The difficulty of the diagnosis lies in the proverbial difficulty 
of proving a negative. It is not wise or honest to make an off- 
hand statement that no organic change of tissue exists to ac- 
count for the phenomenon. And moreover, I believe that long, 
continued hysterical vomiting may lead to organic change by the 
unnaturally empty state of stomach which it perpetuates. It 
may lead to congestion of the mucous membrane, and thus to 
ulceration. You must watch your patient carefully and note all 
indications of the organic disease or the contrary before you 

* This girl, after retaining mutton-chops and porter for a fortnight, and ex- 
hibiting her muscular powers by a walk to Oxford Street and back, went home 
well July 13. T hear from one of my pupils that she has this winter not only 
relapsed into her former condition, but has communicated it to a neighbor of 
her own age. Dec. 1863. 



HYSTERIA. • 429 

decide ; for though with the hysterical temperament it is the 
most common case for no actual lesion to be found, yet the 
chance of it is not entirely excluded. 

But the first thing to do is to observe whether the hysterical 
temperament exists. For this knowledge no guide is so sure as 
that peculiarity of eye and manner which I have often described 
to you, and which is so strongly marked in this instance that 
there was but little question as to the nature of the ailment 
being at all events much affected by it. 

In the treatment I adopted a plan which has been justified by 
success, and which is also justifiable on rational and physiological 
grounds. I ordered that food should be taken only in small 
quantities, but frequently, and always in the standing posture. 
She was made to stand up and eat every hour. The object of 
making the patient swallow only while erect, is to give the 
oesophagus the aid of the force of gravity and also to relieve it 
of that muscular effort necessary for its action when horizontal. 
The method is of essential importance in the treatment of func- 
tional regurgitation, and is also not without its use in cases due . 
to organic change, ulcerative or malignant. I am surprised not 
to find it alluded to in practical works on the subject. 

The view proposed by cold shower-baths is the strengthening 
of voluntary power. The warm season we are having has allowed 
of their being taken twice a day, but in colder weather that is 
often too much, and may bring on catarrh or catarrhal rheu- 
matism, or catarrhal sore-throat. Indeed one bath a day will 
sometimes do that in this chilly climate. A good precautionary 
measure in females is to guard the head from the water ; for the 
soaking of their long hair keeps it wet for an hour or more, and 
is more apt to give catarrh than the shower-bath itself. 

Hysterical vomiting is more difficult of cure by mere drugs 
than any other manifestation of the diathesis; for the usual 
entrance for your means of cure is barred against you. I say 
designedly " barred," because really the articles swallowed do 
not get into the stomach ; they are not, strictly speaking, vom- 
ited, and the phenomena are in fact more analogous to those of 
oesophageal stricture. For this reason the emaciation is not so 



430 HYSTERIA. * 

great as in chronic cases where the stomach is emptied by true 
vomiting ; for, though thrown up immediately, and to all appear- 
ance wholly, yet in reality some of the mass swallowed slips 
through the spasmodic grasp of the oesophagus, descends into 
the stomach' and keeps up the nourishment of the body. 

You need not, therefore, be in so much alarm about hysterical 
vomiting as the symptom would at first appear to justify. The 
patient will not be starved so soon as the friends expect, and 
there is plenty of time for judicious treatment to be adopted and 
to act. 

In this form of hysteria, as in those with more obviously mental 
manifestations, a change of scene and habits has a marked effect, 
even although the present circumstances are not deleterious. I 
do not think you would have seen so quick a cure of this woman 
at her own home. 

I had a whimsical instance of this last-named fact in a maiden 
lady aged nineteen, who was sent up to me by Mr. Ayres, of 
Ramsgate. After a preface of hysteria, she had had daily rejec- 
tion of food for six months, sometimes of everything taken, but 
always unchanged in appearance, showing the vomiting to be 
oesophageal and not gastric. Soon after she came to London 
she got well. She went home to Ramsgate, and, being soon 
afterward frightened by a chimney on fire, was taken with her 
old vomiting again. She returned to London, and the same day, 
without any remedy, the vomiting ceased, and she swallowed 
everything easily. It was the most u veni, vidi, vicV cure I 
ever saw. 

Not but that care and decision will enable you to be victorious 
sometimes even in cases where removal of dwelling is impossible. 
Dr. Woodhouse, of Hertford, called me in to see a case of vomit- 
ing in an hysterical young married lady, where, either from mis- 
placed catamenia or congestion from retching, blood was thrown 
up in considerable quantities. We succeeded in entirely removing 
all food, and in feeding her with beef-tea enemata for a fortnight, 
after which she gradually got back by the steps of spoonfuls of 
milk to ordinary diet, and Was cured completely. But Dr. 
Woodhouse quite tired himself out by the watchfulness and de- 



HYSTERIA. 431 

cision lie had to exert to get this plan carried out. Several 
times we were almost driven to despair of success. You must 
be ready for a course of decisive and sometimes unrequited 
labor in managing such cases. 

I extract from my note-book of a few weeks ago a case analo- 
gous to the last, in so far that the deficiency of healthy control 
was exhibited in the same set of nerves, namely, the pneumo- 
gastric, but exhibited in a rarer form. 

Fanny T., aged twenty-one, was last year thwarted in hopes of 
gratifying at once her affections and ambition by a very advan- 
tageous marriage. She is a reserved proud girl, and very de- 
termined to make no sign of weakness by showing herself as 
low-spirited or hysterical. She had made up her mind to be 
independent of marriage altogether, and with a view of securing 
fame and fortune in the world of letters had been working very 
hard at French, German, and Latin literature. In consequence 
her general health was failing, the bowels became costive, and 
the catamenia had been irregular the last six months, occurring 
sometimes every fortnight, and sometimes having intervals of 
five or six weeks. She had also got thin and strangely lost her 
muscular strength, so that she was tired with the least walk, and 
dropped from sheer debility articles of furniture and the like 
which previously she was used to carry with ease. For the last 
three months she had been troubled with a cough of a peculiar 
loud barking character, very spasmodic and uncontrollable, un- 
accompanied by any pain, and not followed by any expectoration. 
At first it used to come on only when she was exhausted with 
actual exercise, but latterly it had got much worse, and was ex- 
cited by even the effort of speaking to any one or by seeing a 
stranger, or even by allowing her thoughts to dwell long on any 
exciting subject. She had taken large quantities of expectorants 
and felt confident that they made her worse : the breast was red 
and raw from the application of mustard poultices, without even 
temporary benefit being derived therefrom. In fact, no medicine 
had done any good. 

A stethoscopic examination of the chest showed the lungs and 



432 HYSTERIA. » 

heart to be quite healthy and remarkably well developed. But 
what surprised me more was the absence of hysterical manner 
and aspect, and the extremely reasonable way in which she spoke 
about her ailments. It was more from the history and her own 
statements, than from my own eyes, that I was able to guess at 
the hysterical diathesis. 

I look upon this as an instance of a strong external disposing 
cause overcome in a great measure by a still stronger will. In 
a weaker-minded woman it would probably have resulted in the 
extremest hysterical phenomena; in her it acted only locally on 
one set of nerves. I dare say at a future time I shall be able to 
show you examples of the same thing in patients under your own 
observation. 

It is worth while to notice in passing an illustration we have 
also had of the contagiousness of hysteria. 

Elizabeth W., aged eighteen, has been in hospital many weeks 
with several relapses of rheumatic fever coming upon a long dis- 
eased heart. She has been all along somewhat disposed to hys- 
teria, but never so much as to require special remedies. Our 
patient with hysterical vomiting, Hannah P., being up and about, 
was appointed by the nurse to give her her food, and was brought 
into familiar relations with her.* In a few days Elizabeth W. 
began to vomit her food also, and this led me to order her vale- 
rian. The drug, a good scolding, and the removal of the conta- 
gious intercourse with Hannah P., soon put a stop to the addi- 
tional ailment, and I have bidden her continue the valerian as a 
preventive and tonic. 

Part III. — (Clinical, St. Mary's, February 5, 1863.) 

In the case of Elizabeth P., who has just left us, you have seen 
an example of the connecting link between hysteria and insanity. 
She is a servant out of place, aged twenty-two, muscular and 
well-made, but thin, and of leucophlegmatic color and aspect. 
She was sent in as a case of inflammation of the bowels, and I 
found her in bed loudly complaining of violent pain in the abdo- 



HYSTERIA. 433 

men, equal in external manifestations to that caused by perito- 
nitis. But then she lay twisting herself about, and when I put 
my hand on the part she immediately contracted strongly all the 
muscles. People attacked with peritonitis do not do that. She 
gave moreover no history of shiverings, or of any probable cause 
of peritonitis ; whereas that inflammation is always preceded and 
accompanied by rigors, and can generally be traced to some defi- 
nite occasion. Then she buried her face in the pillow, avoided 
my gaze, and, when pressed to look at me, did so with a quick, 
startled glance, and quickly turned away her eyes. The pupil 
was widely dilated, the sclerotic sky-blue, giving the organ a 
much brighter and blacker appearance than is consistent with 
her blonde complexion. There was the hysterical droop and 
fullness in the upper eyelid. The catamenia were regular, and 
she had no leucorrhoea. The urine was very pale, copious, and 
of a specific gravity only from 6 to 7 parts in 1000 above that 
of distilled water. This again was fatal to the diagnosis of peri- 
tonitis. There was a great abhorrence of food, but no vomiting, 
and it did not seem to cause any inconvenience when swallowed. 
On all these grounds taken together I set it down as a case of 
hysteria, psychical rather than bodily in its manifestations, and 
depending rather on moral than on material causes. 

Subsequent information has seemed to confirm this view. 
There is some sad point in her private story which seems to 
have been the starting-point of her illness. What it is I do not 
know, and more than that I do not care to inquire ; for I believe 
inquiry would do more harm than good; the fact is enough. 
You will often be tempted by natural interest and a pardonable 
curiosity to elicit romances of real life from your patients. And 
there is an agreeable sense of responsibility in being the honor- 
able guardian of a secret. Women more especially, from an 
innate love of confession, will favor this, and are only too ready 
to make you a confidant of their own and ' others' histories. 
Check yourselves and check them, directly you have heard 
enough to direct your treatment of the case. Overmuch sym- 
pathy with mental distresses and passions makes you a less effi- 
cient medical man; even the appearance of sympathy weakens 



434 HYSTERIA. > 

•» 

your influence in many hysterical cases. It is your business to 

discourage a morbid dwelling on the past, and to strengthen that 
English reticence which leads us to bury our sins and sorrows in 
some out-of-the-way corner of the memory, and to resent the 
prying curiosity of medical or spiritual attendant. 

The diagnosis of hysteria was confirmed even before we left 
the ward by the patient going off into a violent attack of noisy 
sobbing ; and the nurse told me that a few days afterward some- 
thing made her laugh, and sh§ was quite unable to restrain the 
most violent and painful cacchinations for a quarter of an hour. 
But it also appeared that before her admission she had had tem- 
porary delusions on various subjects, and often her manner in 
the hospital was that of a melancholic. By clint of valerian and 
daily shower-baths she got much better, and was able often vol- 
untarily to keep off hysterical paroxysms, when she heard that 
having them would entail a shower-bath in the afternoon and at 
night as well as in the morning. 

But her frightened insane manner she did not lose till we were 
able to set her to work helping the nurses to wash the crockery, 
run messages, and wait on the patients. This was much better 
than the dull walks up and down the garden, which for some 
time was all the voluntary exertion she could be got to make, 
and it quickly wrought a cure. 

Part IV. — [Clinical, St. Mary's, November 14, 1863.) 

In the case of Ellen who left the female wards two or 

three days ago, cured of hysterical vomiting by valerian and 
shower-baths, there are a few circumstances worthy of practical 
note. 

She states that for the last three years she has scarcely ever 
passed a month without an attack of vomiting accompanied by 
great depression of spirits. These attacks, however seldom last 
above four or five days, and are usually cured by stimulants. 
Last August she went to Eastbourne along with the family 
where she lives as cook. It was against her will that she went, 
for she says the seaside never agrees with her. While there she 



HYSTERIA. 435 

had an erysipelatous inflammation of the foot, which laid her up 
for a short time, and her spirits got depressed. Then a very- 
bad attack of her old complaint came on; she vomited after all 
her food, and continued to do so till her admission to the hospi- 
tal, October 22, after she had gone on suffering in the same 
manner for two months. 

She is a tall dark unmarried woman of thirty-three ; she has 
an imposing aspect, with a fine-looking mouth and jaw ; but yet 
she has the hysterical eye. Or at least she had it on admission, 
for her expression is a good deal altered since she came. She 
has never experienced paroxysms of laughing or crying, and is 
used to conquer her depression of spirits by an effort of throw- 
ing it off. She seems a person of strong hysterical diathesis, 
checked by sound good sense and powerful will, in whom the 
diathesis would not have developed into external manifestations 
without considerable motive causes. These motive causes may 
be traced in her history. 

You observe, first, her age. A single woman between thirty 
and forty is in circumstances which have a great influence on 
the mind. She feels that her chances of a settled and natural 
home are daily becoming less and less, and that the affections 
she might expend on a house, a family, and a husband, are being 
wasted and withered. Hence their tendency to all mental and 
semi-mental ailments. 

Secondly, early in life her affections were cruelly deceived 
and blasted. Long ago she was an unmarried mother, and has 
ever since suspiciously shunned the chance of a similar disap- 
pointment. 

Thirdly, her bodily vitality was lowered by the depressing 
illness of erysipelas. 

Fourthly, she was in a climate which tended to aggravate the 
predisponents already named. . Many hysterical persons are 
made worse at the seaside ; and moreover close to Eastbourne 
there are some recently drained marsh lands, whose crop of 
malaria is in certain states of the wind blown toward the town. 
The eastern side is especially exposed to this. Now malaria 
is very poisonous to all nervous patients; it does away with 



436 HYSTERIA. * 

all the advantage of the fresh sea breeze and the change of 
scene. 

It is in such cases as this, where there is under ordinary cir- 
cumstances a balance between the disease and motive causes on 
the one side, and the natural cure of strong will on the other, 
that you find the more irregular forms of hysteria developed. 
And I must frankly say they are not easy to recognize, and 
often difficult of cure. 

I kept this woman at first in bed for a few days, in order to 
give her perfect rest, and to enable her to do without more than 
a very small allowance of nutriment, namely, milk and beef-tea 
given in doses of about two ounces at a time. This broke to a 
great extent the habit of vomiting. Then she had a teaspoonful 
of tincture of valerian every four hours, and strange to say its 
nauseous taste produced no nausea. The cure was completed by 
a week's course of daily shower-baths. The woman herself was 
much struck with the effect, and in spite of this dreary weather 
said she was determined to go on with them at home. Her 
mistress will doubtless accede to this plan of keeping an active 
servant in vigor, and armed with a prescription for valerian drops 
I think our patient is qualified to be her own physician. 

Compare this now with the next case. Jemima T., a house- 
maid, aged twenty, has at present hysterical aphonia. She 
was originally admitted September 28 for severe (Edematous 
angina. She had been salivated before admission, and was fur- 
ther reduced through the loss of blood by leeches, uncompensated 
by diet ; for swallowing was so difficult to her, that she was 
nearly starved. At first I attributed the loss of voice, remain- 
ing after the angina was well, to paralysis of the vocal cords 
from the long-continued oedema in the neighborhood, especially 
as the edges of the glottis could be seen by the laryngoscope to 
be somewhat red. But when we made the attempt to apply gal- 
vanism internally to the cords, the true nature of the aphonia 
was made known to us by her having an hysterical fit of a vio- 
lent convulsive character, in which she screamed out lustily in a 
high musical note. I immediately ordered her cold shower- 
baths daily and valerian. She has had no more hysterical par- 



HYSTERIA. 437 

oxysms, but shows in the shower-bath her talent for holloaing, 
and the voice is acquiring a tone. 

I have brought forward this case in order to remark that 
where any special lesion has existed, hysteria will very often 
choose the lesed locality for its manifestation. This is puzzling 
to you in practice, because you do not know when to cease treat- 
ing the ]esion and to begin treating the hysteria. I think the 
general tendency is to be too dilatory in changing the treat- 
ment. 

I have also to remark an instructive clause in this girl's his- 
tory. She is a native of Edinburgh, or at least was long resident 
there, and always enjoyed very robust health and high spirits, 
and never felt tired. But on her coming to London, eight 
months ago, this high health almost immediately began to fade, 
her nervous powers declined, so that she never felt up to a good 
day's work, and she fell into a state of perverted nervous sensi- 
bility of which you see the phenomena. I cannot help attribu- 
ting her illness to the depressing influences of the climate of 
London on a person used to the stern bracing air of the East of 
Scotland. 

[This girl regained her voice and general health, and left the hospital Novem- 
ber 27 to take an opportunity which offered itself of returning to Edinburgh.] 

Another case of hysterical aphonia came in last week. Sarah 
L., aged twenty- eight, lost her husband two years ago after a 
pulmonary consumption, which had laid him up for five years, 
and during which she had nursed him assiduously. She says 
her health has never been strong since, though she cannot give 
a name to her illnesses : she has been frequently prostrated by a 
feeling of excessive weakness, but has had no definite classifiable 
ailment. So she continued till a fortnight ago, when she quite 
lost her voice, and then was taken with a severe cough, which 
"quite tore her chest to pieces." A few days before we saw 
her here she began to spit up blood, but I could not make out 
from her account that the blood came up with the cough. When 
I first examined her she complained of exaggerated pains all 
over, and her whispering attempts at conversation brought on a 
paroxysm of a violent spasmodic character, like hooping-cough 



438 HYSTERIA. 

without the hoop, but it resulted in no expectoration. She 
said she was sure she was going into a consumption, but per- 
cussion and auscultation of the thorax gave no evidence of any 
pulmonary or cardiac lesion. The next day she showed me 
a quantity of slimy blood in a porringer, which she had spat 
during the night and day. Blood it was truly, but yet it pre- 
sented to the eye not exactly the aspect of that which might 
come from the lungs. It was neither scarlet nor frothy, like 
that so common in early tuberculosis, nor did it consist of streaks 
in the mucus, like that of a more advanced stage, but it was 
incorporated with and soaked into the mucus, more like what 
you have in congestive pneumonia. Now she certainly had not 
congestive pneumonia, and therefore I believe it does not come 
from the pulmonary tissue at all. This view is confirmed by 
the nurse, who says the patient does not cough it up, but hawks 
it up very gently. My own impression is that it is drawn down 
into the fauces from the back of the nose or comes at lowest 
from the trachea. 

What renders the case more complicated and puzzling is, that 
her breath is fetid and her tongue coated with a white fur, from 
some mercurial medicines which she had been taking before 
admission. It is very like the tongue of inflammatory fever. 
But then to balance this element of difficulty in the diagnosis, 
she has hysterical paralysis of the lower extremities, being 
really unable to stand, and stumbling forward on the floor when 
I left her alone without support in the middle of the room. The 
form of paralysis is sufficiently special to mark its hysterical 
character,* and compensate for the other difficult points of 
diagnosis. 

It seemed perhaps rash and cruel, when to a patient who thus 
exhibited the symptoms of haemoptysis, cough, loss of voice, 
pain in the chest, quick pulse, and furred tongue, I straightway 
ordered valerian draughts and a cold shower-bath every morn- 
ing. But I felt safe in my diagnosis from the characteristic 
appearance of the eyelids and the dilated pupils. She said she 
was sure that the shower-baths would kill her ; but she survived 

* See before, page 428. 



HYSTERIA. 439 

the first, and after the second confessed that it did her a great 
deal of good. She is improving rapidly, and seems now really 
desirous of being well, submitting without a murmur to the 
moral influence which I have desired the nurses to exercise, in 
giving her employment, and not allowing her to lie down and 
think, as she is prone to do. 

This case is an instance of the enormous advantage over our 
forefathers which auscultation gives us. Without the stethoscope 
it would have been a most anxious thing, nay almost impossible 
for even the most shrewd to have pronounced the negative 
opinion that this blood did not come from the lungs, and that 
the cough was not produced by rapid tuberculosis. It is an 
instance also of the reward which follows bold and decided action 
in these cases. 



Part V '.—(Clinical, St. Mary' 's, November 28, 1863.) 

Sarah L. went on very well, having lost her cough and 
hsemoptysis, and recovering the use of her"legs under the ad- 
ministration of a cold shower-bath twice a day, and valerian, till 
November 23. Then her monthly period began in the usual 
way, and according to established practice the ward-sister 
ordered the shower-bath to be discontinued. Sarah L. took to 
her bed next day, and began again coughing violently, and 
expectorating, really expectorating this time, a quantity of 
frothy bright blood with each cough. There was as much as 
half a pint spat up in twenty-four hours. Yet the catamenia 
continued to flow, though scantily. I found her on the 25th in 
bed, tortured with violent paroxysms of coughing, and throwing 
up blood each time. I took a slab of ice, and placing it on the 
sternum, directed her to hold it there with a piece of flannel. 
The paroxysmal cough and the haemoptysis ceased forthwith, 
and when I saw her next day, she said she had kept constantly 
applying the ice, and that it always stayed the cough immedi- 
ately. The catamenia continued. I bade that on their ceasing 
she should resume the shower-baths. But this morning, when 
the nurse, finding the prescribed time for their resumption had 



440 HYSTERIA. % 

arrived, ordered her to have one, she refused, and when remon- 
strated with, still persisted in her refusal, though acknowledging 
all the good they had done her. Our necessarily strict rules of 
discipline render her, therefore, no longer a patient at the hos- 
pital, I am sorry to say, for I was very anxious to see the result 
of this curious and instructive case. 

Several examinations which I and others made of her chest 
convince me that there was no lesion of the pulmonary tissue, 
such as usually gives birth to haemoptysis. I own at first, and 
even at the time of my last lecture to you, I was suspicious that 
the blood was produced by a voluntary effort, such as may be 
exerted on the back of the fauces, or nasal fossae ; but observa- 
tion of this last attack completely exculpates the patient in that 
respect. No voluntary effort could cause the blood to be exuded 
in such quantities into the trachea, for auscultation showed it to 
be in the trachea, not the bronchi. Then its occurrence at the 
menstrual period induces me to range it in that curious, and, 
fortunately, rare class of cases, where the monthly hemorrhagic 
nisus of the female sex, instead of confining itself according to 
the convenient arrangement of nature to the womb, an out-of- 
the-way and secret part, is exhibited in other more conspicuous 
and troublesome places. 

Some of my third-year hearers may, perhaps, remember a 
remarkable instance of this misplaced discharge in a young wo- 
man who was in the hospital two years and a half ago. She 
menstruated by the usual path, but at the same time had an 
exudation of blood in minute puncta, fr'om the skin of the arms 
or forehead, or legs or chest.* I called it then a case of "bloody 
sweat," for in looking at her pale face and gore- dabbled brow, 
a memory of Grethsemane could not fail to offer itself, and I 
hope such memories are not irreverent. She also, like our 
present patient, was hysterical, was suspected of imposition, 
and carefully watched, but no deception could be detected. 

When that case of catamenial bloody sweat was admitted, I 
did not know at all how to treat it, but I found experimentally 

* Full details of this case and the literature of the subject are published in 

the " Lancet" of March 2, 1861. 



HYSTERIA. 441 

that free leeching the spots where tenderness gave notice of 
threatened haemorrhage, not only prevented the immediately 
imminent haemorrhage, but gradually lessened the tendency to it. 
She had seventy leeches applied in this way, and lost beside by 
venesection twenty-four ounces of blood; yet she gained strength, 
and became less hysterical, and went out nearly well after four 
months. She had a recurrence last year, when I saw her once, 
and ordered her some leeches as an out-patient. And again a 
few weeks ago you saw her in the ward, having come to apply to 
me for some leeches to relieve a slight recurrence, in the cheek, 
of her old complaint. She stated that she had been previously 
free of it for many months. 

This last-named case shows that in misplaced catamenia with 
hysteria leeches will cure the haemorrhage, without damaging 
the mental state ; and it was my intention to have tried an analo- 
gous method of treatment in Sarah L.'s case, but her abrupt 
departure has defeated my design. 

In all my lectures on hysteria, the conclusions to which I have 
endeavored to lead you by aid of the patients under your eyes 
are — 

1st. — That it is a disease (a word which I always use as 
synonymous with deficiency of life) of the mind and of the body 
also. 

2dly. — That in some cases the mental, in others the corporeal 
phenomena predominate. 

3dly. — That the predominance of one or other must be our 
guide, whether moral or physical agents are most required in the 
treatment. 

4thly. — That the aim of our treatment of the mind must be 
the teaching our patients to exert their will. 

5thly. — That the organ which aids us most in our treatment 
of the body is the stomach, and on the proper regulation of this 
viscus the success of that part of our practice will depend. 



29 



LECTURE XXXIII. 

SPINAL PARALYSIS. 

Case of 'paralysis caused by meningitis of the spinal cord — Action 
of iodide of potassium. 

{Clinical, St. Marys, June 27, 1863.) 

Meningitis of the spinal canal, about which I am going to 
lecture to-day, does not present the interest of frequency. It 
may perhaps be many years before you have a case of it to treat, 
perhaps you may never see another. But the fact is, I have not 
to-day any more instructive cases to lecture about, and I will try 
and extract for you from it what wisdom I can. 

William T., a pale-faced, sandy-haired, and delicate-looking 
shop-boy of seventeen, has been under your observation since 
April 10. He stated that his father and mother were alive and 
healthy, and that he himself had always been well till Wednesday 
in Passion Week (April 1), when he had to carry a heavy load 
on his shoulders ; while thus employed, his foot slipped and he 
fell down against a wall, but did not knock his back or bruise 
himself. At about two o'clock the following afternoon pain 
came on suddenly in the lower part of the loins. He however 
went on with his work that day ; he had a holiday the next, 
being Good Friday, and worked again on Easter Eve. But on 
Easter Sunday the pain was so bad that he took to his bed, and 
lay there till the Thursday after, when he got up and sought 
medical advice, as the pains in the back were so bad that he could 
not sleep at all. On the Saturday, April 11, he walked to the 
hospital, and was sent to bed. But though he walked, he said 



SPINAL PARALYSIS. 443 

his left leg was very painful and numb. He complained of great 
thirst, the skin was hot, the pulse quick and sharp, and the 
tongue thickly coated with a yellow fur. 

At first he was treated with chloroform fomentations to the 
loins, as for rheumatic lumbago ; but two days after admission a 
more accurate examination detected the seat of the pain to be in 
the situation of the last lumbar vertebra at its junction with the 
sacrum. The pain was much increased by pressure and by per- 
cussion. Both legs then appeared to be growing numb, and 
there was some difficulty in moving them. But the sphincters 
were as yet unaffected, and he retained his urine and faeces 
naturally. 

These symptoms led to the diagnosis of meningitis of the spinal 
cord. He was cupped to eight ounces at the painful spot on that 
and the following day, and a continuous chloroform poultice was 
kept on the sacrum. 

The paralysis of the legs increased, and sensation became very 
deficient, so that he scarcely felt the hot water bottle at his feet. 
He was then (on the 15th) ordered ten grains of iodide of potas- 
sium every three hours. On the 18th there was less inflamma- 
tory fever, and the tongue was cleaner. But the sphincter of 
the bladder had become paralyzed, and the urine trickled away 
involuntarily. A catheter was then passed and the bladder found 
to be full, being incapable of spontaneously emptying itself. 
The urine drawn off was alkaline, and contained a small quantity 
of floating pus globules. Then he entirely lost command over 
the sphincter ani, as well as over the bladder, and lost also all 
sensation of the passage of either fluid or solid excrement. The 
urine was drawn off three times a day, and constantly contained 
a large quantity of ropy pus, sometimes quite obstructing the 
catheter. The iodide of potassium was continued in the same 
doses, with no addition except that for two days he had with it a 
few drops of tincture of cantharides, which was left off on the 
bladder being inflamed, and occasionally a little tincture of 
opium, to make the faeces more solid and less troublesome to 
those who cleaned his bed. 

The paralysis was at its worst about the 30th of April, after 



444 SPINAL PARALYSIS. 

which it began to mend, first in the legs, and afterward in the 
sphincter ani, and then in the sphincter vesicae. The amendment 
in the two latter seemed to be considerably aided by the appli- 
cation of blisters on the sacrum and above the pubes. The 
patient can now move his legs about freely in every direction as 
he lies or sits on the bed, and can voluntarily retain his faeces 
and urine. He can prevent himself from making water for an 
hour together. He is, however, excessively emaciated and weak 
and cannot of course walk about much. The introduction of a 
catheter into the bladder shows that it spontaneously empties 
itself, so that the muscular action has completely returned ; but 
still there is a certain amount of floating pus in it, and it is 
seldom decidedly acid. He is taking decoction of uva ursi and 
cod-liver oil, and improving daily in every respect. 

[He left the hospital fat and well at the beginning of August, without any- 
purulent secretion from the bladder remaining.] 

I take this case to have been one of meningitis of the spinal 
cord ; that is to say, inflammation of the white fibrous coverings, 
and not of the nervous tissue itself. Instances of disease of this 
part are rare, and therefore one cannot of course be very pedanti- 
cally positive in reasons for a diagnosis. My principal reason 
was the presence of local pain ; for in disease of the spinal cord 
itself there is no pain, as some of you may recollect to have seen 
in the case of a young woman who died with a scrofulous tumor 
in its lower part, last winter session. The cause of her death was 
chorea, but there was no paralysis or local pain. Local pain is 
also absent in cases where haemorrhagic clots, tumors, or inflam- 
matory softening occupy the central parts of the cerebral mass ; 
while it is on the other hand almost always present when the 
dura or pia mater are affected. 

My clinical clerk, Mr. Philps, has shrewdly suggested another 
reason for the diagnosis, namely, that the pain was situated very 
low down, to wit in the lowest lumbar vertebra. He says that 
as the cord has given off all its nerves and ended at the level of 
the first lumbar vertebra, any pain referred to a situation below 
that must be in the envelopes which continue to surround the 
bundles of nerves, rather than in the cord itself. And I think 
his reasoning very good. 



SPINAL PARALYSIS. 445 

As to the origin of the disease in this case there is not much 
to help conjecture. Possibly a rupture of some fibers of the psoas 
muscle by the strain in stumbling under a heavy burden may 
have started an iuflammation in the interior of the pelvis, which 
affected secondarily the coverings of the sacro-spinal plexus, and 
so spread upward. Possibly there may be some scattered tubercles 
in the meninges of the cord or its theca, just in sufficient numbers 
to excite a curable inflammation, but not an incurable one. We 
have not enough data on which to found an anatomical diag- 
nosis. 

But we have plenty of data for the foundation of a therapeu- 
tical diagnosis. There was paralysis of the lower nerves of the 
spinal cord, probably from inflammation of its meningeal cover- 
ings. And on this was based the treatment by iodide of potas- 
sium. You may know from observations of its use in tendinous 
and thecal rheumatism, in aponeurotic headaches, in chronic 
syphilis, in periostitis, in inflammation of the eye, in hard en- 
largements of the glands by disease of their connective tissue, in 
some of the consequences of gonorrhoea, &c, how this drug causes 
a renewal of healthy life in white fibrous tissue, without any 
evacuation or destructive action, as is shown by the patient's 
increase in weight during its appropriate employment. By its 
action on that tissue I explain its use in such cases as these. I 
employed it once as the only drug in a case of meningitis of the 
brain in a young man with the best results, and shall be disposed 
to trust to it with equal confidence in future. 



LECTUEE XXXIV. 



SCIATICA. 



Anatomical pathology of the disease — Case of rheumatic sciatica 
— Hokitanskys description of the morbid anatomy of sciatica 
— The disease a local one — Therefore requiring local reme- 
dies — Case of gouty sciatica — Relief from cupping — Per- 
ipheral pain sometimes more lasting than central disease — 
Sciatic paralysis of bladder — Case of ansemic sciatica — 
Local treatment first requisite — Use of iodide of potassium 
— And of quinine — Other forms of sciatica — Other remedies 
besides those named — Deductions and reflections. 

[Clinical, St. Mary's, January 26, 1861.) 

Three of my patients now under view in the wards are in- 
dexed as cases of "sciatica." The term, though Latin, is not a 
technically pathological one ; for it no more defines a morbid 
process than the vulgar English "headache" or "stomachache." 
Like those words, it points out the anatomical locality of the 
symptom, and is applied to pains in the great sciatic nerve, 
whatever their nature or cause may be. 

It will better impress upon your minds several important 
points in its pathology and treatment, if I recall to you a few of 
the anatomical relations of the part affected. The sciatic is the 
largest nerve in the body ; and on that score even slight inter- 
ference with it may be expected to be severely felt. It is formed 
hj a union of the sacral nerves ; which, inside the pelvis (form- 
ing the sacral plexus), are covered on the left side by the rectum, 
and on the right side are in close proximity to the caecum ; — 
hence it is very liable to be influenced by the condition of 



SCIATICA. 447 

either of these portions of the intestinal canal separately. It is 
covered by a strong fibrous sheath, and may of course be ex- 
pected to experience morbid states which attack such membranes. 
It supplies motion as well as sensation to the lower limb, and 
therefore loss of muscular power often follows its loss of vitality. 
Inside the pelvis, branches are sent from the sacral plexus to the 
bladder and other pelvic viscera ; so you will not be surprised 
to find in sciatica occasional paralysis of the bladder. After it 
passes beyond the border of the pyriformis muscle, it lies nearer 
the surface than any great nerve, and it goes straight from one 
of the warmest berths in the body to one of the coldest ; and 
that it is soon affected by changes of temperature is readily to be 
understood. 

The first case which I shall mention is a good instance of the 
last-named fact. The affection is strictly local and pretty recent, 
and is clearly traceable to a local change of temperature acting 
on this part of the body alone. 

Case 1. — Henry T., aged twenty-eight, a horse-patrol, of 
temperate and regular habits, had been quite well up to the 
second week in December, when he got wet in the saddle several 
nights running, and his buttocks and thighs were much chilled. 
This was followed by cold and shivering, but by no particular 
pains in the limbs. Suddenly, while grooming his horse, he. was 
seized with a twinge in the hip, which made him walk lame and 
prevented his sitting on horseback, but did not quite lay him up. 
He continued with the aid of a stick t§ go through his beat a-foot 
instead of riding. One day, and one day only, before Christmas, 
the pain quite went away ; but, with that exception, it became 
worse and worse. Since December 20 he had been laid up un- 
able to stand, so bad was the pain ; and he had had croton oil 
rubbed in externally, mustard poultices, and blisters, without 
the least relief. The tongue, pulse, and action of the bowels 
were reported natural, the urine clear. The situation of the 
pain, as pointed out by one finger, was the exit of the sciatic 
nerve, and pressure on that spot much increased it. He told us, 
also, of a pain deep down in the pelvis, as if it lay at the back 
of the groin. 



448 SCIATICA. * 

There is here a purely local disease, asking for local remedies. 
The morbid anatomy of it I cannot describe from any observa- 
tion of my own ; none of us possibly ever have seen, or ever will 
see, the necropsy of a person who dies during sciatica ; it is not 
itself deadly, nor does it accompany deadly diseases. But Pro- 
fessor Rokitansky describes the sheath of the nerve as filled with 
a yellow gelatinous fluid, and as having its blood-vessels injected 
in sciatica. This is just what you find in the rheumatic inflam- 
mations of other fibrous parts, and what a general knowledge of 
pathology would teach us to expect ; and, therefore, I fully be- 
lieve it is the unseen state in this and similar cases. It is a local 
disease asking for local remedies. You will say, it has been so 
treated in this case, and it has not got well. True ; but the 
remedies were, for all that, of the right sort ; perhaps not quite 
powerful enough, and, moreover, not quite local enough. What 
does that deep-seated pain in the pelvis mean ? It shows that the 
sacral plexus is affected, as well as the trunk of the nerve ; that 
the remedies must be applied to that part to have their full 
effect. Such, I take it, is its meaning. Now, applications to 
the skin of the hip and thigh are a long way off the sacral 
plexus, and you would not get much nearer by placing them on 
the groin. But you can get close to, indeed quite on, the seat 
of action, by calling to mind how the plexus is overlaid by the 
rectum. His former treatment, mustard poultices, blisters, and 
croton oil, would be rather difficult to apply to that part cer- 
tainly ; but you can use an* allied remedy, turpentine ; and you 
can introduce it to the pelvis either by enema or by the mouth. 
The former method is the most direct ; but I have chosen the 
latter in this case, for the mutual convenience of nurse and 
patient. His card records the following : 

Jan. 14. 1^ Olei terebinthinde, olei ricini, mist, acaciw, aa 
§ss; mist, c amphorae, §j- M. Fiat haustus mane sume?idus. 

Jan. 16. Repetatur. 19th. Rep. 21st. Rep. 24th. Rep. So 
that five doses of turpentine in all have been taken. On the 
16th the pain in the hip was much relieved, but he had a little 
strangury during the action of the turpentine. On the 19th he 
said he felt better after each dose, though the pain came back 



SCIATICA. 449 

again. The strangury was much less than at the first dose. On 
the 23d, the pain was not felt during the day " a third as bad as 
it was." He could cross one leg over the other in sitting, and could 
walk without pain. But you will have seen that he still walked 
lame, and spoke of a kind of numbness running down the thigh. 
This is a slight paralysis, very usual in sciatica, arising from the 
pressure of the swollen sheath upon the nerve. He said the deep- 
seated pain in the pelvis was gone. You will find the treatment 
here ordered the most powerful to cure the local condition of the 
part affected in sciatica. 

To-day (the 26th) he walks quite easily. But, unfortunately, 
the turpentine, not having sufficient employment in doing good, 
has taken to doing mischief, and has brought on strangury again. 
He has had two grains of opium as a suppository, which has re- 
lieved it to a certain extent ; and, instead of continuing the 
turpentine, I have ordered him to be cupped to four ounces on 
the hip. 

Case 2. — Another patient in the same ward, Francis B., aged 
fifty-three, has no occupation now, but he tells us that formerly 
he did a business of £1000 a year, and enjoyed a famous con- 
stitution. Wealth and health were lost through self-indulgence 
in eating and drinking. He had gout thrice in one foot, and 
once in both feet, twenty years ago. Poverty made him temper- 
ate, but two years ago he had some money left him, and "drank 
it out," being only stopped by a severe attack of bleeding at the 
nose. Since then he has not exceeded, but still had a twinge of 
gout six months ago. After this he was quite well till six weeks 
ago ; at which period, after having felt for three days pains 
flying about him, he was attacked, while sitting before the fire, 
with a stabbing agony in the back and left hip, so bad that he 
was obliged to go to bed. It has lasted ever since, and he has 
generally kept his bed ; as, though he can hobble along without 
actual suffering, he is in constant fear of a twinge. All through 
this last illness there has been a difficulty in voiding urine, and 
the bowels have been costive. He has been under medical 
treatment all the time, and has taken bark and quinine in large 
quantities, and has had blisters on, without being at all relieved. 



450 SCIATICA. * 

On admission, the tongue and pulse were natural. By manual 
examination the chief seat of pain was found to be a spot midway 
between the great trochanter and the tuberosity of the ischium ; 
and in this part there was much tenderness on pressure, and the 
patient had great dread of its being touched. There was pain 
also skirting along the outside of the fibula, but not in any inter- 
mediate place. 

In this case you have seen a different cause for sciatica — 
namely, gout. But whatever the cause, the local condition of 
the nerve is probably much the same, and is better for local 
treatment in all cases — indeed it is rarely cured without local 
treatment. The remedies given here have been pretty active ; 
the patient came here on the 11th, and between that date and 
the 26th he has had five half-ounce doses of turpentine, and has 
been cupped twice to six ounces. For four days he was allowed, 
as an experiment, to have every night fifteen grains of Dover's 
powder, which I expected the turpentine to carry off safely by 
purgation next morning. It did not make him sleep, or appre- 
ciably relieve the pain, so it was left off; for, as a rule, I do not 
like opiates in sciatica. He had less discomfort on the night 
after it was left off. 

On the 18th he said he had experienced great relief after the 
second cupping. Take a hint from this — your second cupping 
will often confer much more marked benefit than the first. 

" He felt pain in the lower part of the leg, but not in the hip 
unless it were touched," says the case-book. You will observe 
that where there is pain in the periphery of the nerve, arising 
from disease in its trunk, this peripheral pain will often last 
longer than that which is at the real seat of injury. Take 
care to retain this fact in your memory, as it will often prevent 
you throwing away uselessly on the branches those remedies 
which should be applied to the trunk. 

On admission, the patient accused the bladder of some want 
of power. I have seen this before in sciatica ; and I believe it 
arises from the vesical branch of the sacral plexus being affected, 
and therefore shows that the morbid condition has penetrated 
into the interior of the pelvis. If it really arise from that 



SCIATICA. 451 

cause, and not from any old stricture, you need not be afraid of 
causing strangury by turpentine. You will have seen in this 
case the drug doing no harm, on the contrary, relieving the 
symptom which arose from a torpid condition of the bladder. 

On the 23d, he bore pressure on the sciatic nerve and walked 
and moved the limb without fear, though w T ith a certain loss of 
power. He had remarked several times, that though the pain 
was relieved after each cupping and dose of turpentine, yet it 
returned before the next. The cause of the disease, the gouty 
crasis, remains, and must be treated, or else he will have the 
sciatica back again. I have therefore prescribed — 

3^ Vini colchici, TTJxx, potassi iodidi, gr. iv, mist, camphorw, 
oj. M. Fiat haustus ter die sumendus. 

Case 3. — Sarah B., aged nineteen, maid-of- all-work, pale and 
greasy-faced, with cheeks and shoulders covered with black- 
heads (acne), was admitted January 11. She has had occasional 
pain in her hip three years. It came on first when she was out 
of place, and had frequently got wet in her feet. She has often 
felt pains flying about her limbs, but has never been laid up 
with any distinct attack of rheumatism in her hands or feet. 
She often coughs, has been always pale, subject to leucorrhoea, 
and to pain in the epigastrium at night and after food. Her 
bowels are costive, and her appetite bad. She became lame 
from sciatica a few days before Christmas, and took to her bed 
during the last few days of the year, because the pain got so 
much worse. Although an out-patient at the hospital, she does 
not appear to have attended regularly ; so that Dr. Sieveking, 
under whose care she was, sent for her to come in. On admis- 
sion, her tongue was clean ; the pulse was 92, and weak ; the 
urine pale. The catamenia were stated to be always regular, 
except for three months, when she was first ill, three years ago. 
The seat of the pain was clearly pointed out by the finger to be 
the sciatic nerve, and not the hip-joint. The heart and lungs 
seemed quite sound. 

Here is a cause for sciatica the very converse of the last ; 
that was from eating and drinking too much, this is from eating 
and drinking too little. Indeed in a further page of the report 



452 SCIATICA. 

you read a statement of the girl's own, that "the pain sometimes 
entirely goes away, especially after a good dinner ; but always 
comes back again, especially at night." But though scanty diet 
has been the cause of her illness, yet full diet alone would not 
restore health. In point of fact, however much she may swal- 
low, she cannot really eat, that is digest, enough. This is 
shown by the want of appetite and the peculiar dyspepsia ; which 
is described as causing weight at the epigastrium, and inability 
to lie on the left side. 

The local disease required treatment first ; so she was cupped 
once to four ounces and was purged with turpentine ; and she 
took four grains of iodide of potassium three times a day. 

Five days afterward it is registered that " the pain in the 
thigh is less than it was, and she is improved in every way." 

On the 23d, she expressed herself as still better, and was 
walking about the ward. She was put on quinine and iodide of 
potassium. 

The last-named drug I intend to act locally when I give it in 
sciatica. I want it to promote absorption of the yellow gelatin- 
ous fluid which is effused in the sheath of the nerve, and which 
keeps up lameness by pressing upon it, just as you may benumb 
your finger by pressing the ulnar nerve. Iodide of potassium 
has a very peculiar restorative action on the vitality of the 
white fibrous tissues, whether they form tendons, sheaths of 
nerves, or periosteum ; as you may see daily in those parts when 
they have been injured by the poison of syphilis. 

I do not suppose there is any syphilitic taint in this case to 
be benefited by the iodide. Nor, though I give her quinine, do 
I think that the disease is of malarious origin. 

Yet syphilis and malaria do sometimes produce sciatica. The 
syphilitic form is of the same nature as periosteal nodes, but it 
is identical in local effects with rheumatic, gouty, or ansemic 
sciatica. The malarious form is purely neuralgic, and I do not 
think it can ever be accompanied by effusion. It may be dis- 
tinguished by its complete intermittence, and, as far as my 
experience goes, is comparatively rare. The patients usually 
have some other consequence of the ague-poison, which will help 
you to a diagnosis. 



SCIATICA. 453 

Sometimes there is a dull kind of pain running down the 
course of the sciatic nerve in persons with sluggish, costive 
bowels, which, unlike the forms I have been describing, is not 
worse at night, but neither in the day is it attended by paroxysms 
of agony, and it is not made worse by local pressure. This kind 
of sciatica depends, not on the state of the nerve or its sheath, 
but on an unhealthy sluggish condition of the lower bowels. 
When on the right side, it is due probably to accumulation of 
faeces in the caecum ; when on the left (which is the most usual 
case), to piles in the rectum, and the consequently congested 
state of the blood-vessels. It is also not made worse by exer- 
cise ; indeed, I think it gets well sooner when the patient is 
obliged to move about. And for this reason you do not see 
examples of it in the wards, for it is better treated in the out- 
patient department ; whereas in the cases with which I have 
been illustrating the subject absolute rest is essential. 

I do not like in clinical lectures to speak of the treatment of 
forms of disease not at the time under your notice, and, there- 
fore, I will not say more about malarious, syphilitic, and costive 
sciatica. But I think it will be useful, in reference to the three 
cases you have been watching, to notice a few remedies which 
might have been given without glaring malpraxis, but yet which 
I do not think the best under the circumstances. In the first 
place, sedatives might have been considered desirable ; and you 
will find in books a long list, commencing with opium, of those 
which have been administered in sciatica. The very length of 
the list shows how people have been disappointed with the action 
of one after another ; and my own experience is, that the benefit 
from them is temporary, fallacious, and obstructive to the final 
cure. The only one thoroughly unobjectionable is the external 
application of chloroform. Blisters and acupuncture are reme- 
dies of similar intention to those which I have prescribed ; not 
quite so powerful, but equally rational and proper. Plasters are 
of no use during the acute stage, but when the patient is getting 
about again, they are a defense against the cold. Let them be 
spread upon stout soft leather ; for it is the leather, not the 
" emplastrum" that does good, and the kind that will stick 



454 SCIATICA. 

■ * 

tightest answers best. Of electricity and baths I have no favor- 
able experience to tell. I have never seen them of use to the 
local disease after the failure of those remedies which I men- 
tion ; though I dare say mild cases may be relieved by them, as 
also by numerous other expedients, which I need not detain you 
by naming. 

I will tell you why I do not name them. When you have 
once established in your own minds that one particular methodus 
medendi is the most effectual for a particular class of cases, you 
should not continue to retain in your armory, to be used for that 
same purpose, the weapons which it has superseded. It will 
merely burden your memory and confuse your judgment ; and it 
throws in your own path a temptation to wavering. Let new 
weapons be tried by all means, if to the eye of reason they 
promise well ; but let all which have once fairly proved them- 
selves failures be rejected. 

At the same time be not too ready to adopt as fixtures any 
pet plans of treatment. Let them rule for the time, but let 
them be prepared to make way for better when they fail to do 
all that is justly asked of them. Then let their conquerors 
occupy the same post under the same conditions. When you 
have a new remed}^ you want to try, select some cases in which 
your already established treatment has failed, and when you 
have found it succeed there several times, you may fairly depose 
the old monarch in favor of the new. Thus will our art advance. 
The most important moral which I would draw from our ex- 
perience of sciatica is this : to apply to local diseases the needful 
destructive remedies as locally as possible. Do not call upon 
the whole body to make sacrifices for a single member, if you 
can by any means avoid such sacrifices. 

This rule applied to the administration of destructives is 
directly antithetical to that which should guide us in the use of 
constructive agents, where we should prefer in every instance 
constitutional to local action. Remember that in the first case 
we are doing harm for the sake of future good ; in the other we 
are doing general good for the sake of particular good. 



LECTURE XXXV. 

ALBUMINURIA. 

Indications afforded by the presence of albumen in urine, and 
prognosis derived therefrom — Treatment based, not on ana- 
tomical division of forms of degeneration in the kidney, and 
not on the quantity of albumen, but on the circumstances 
accompanying its presence — Adjuvantia, viz., iron, digitalis, 
strychnia— Leedentia, viz., mercury, alcohol — When each 
are justifiable — Treatment of dropsy by baths, jalap, cream 
of tartar, elaterium, and acupuncture — Sloughs of skin, 
how treated. 

The presence of albumen in the urine (or albuminuria) is a 
notice whereby we learn the partial death of one of the most 
valuable structures in the body. It shows the inefficient state 
of those organs through which the urea is separated from the 
blood — the urea, which is a measure of the amount of destructive 
metamorphosis, a measure of the amount of one of the most 
essential parts of vital renewal. The knowledge of this partial 
death is justly regarded as a most important piece of information 
for us to gain. And you see it is easily and quickly gained by 
the well-known test of boiling and nitric acid. 

Remark first — it is as a notice that the presence of albumen in 
the urine is important. The quantity of albumen lost makes 
little difference. The patient would be in a sad way indeed if 
such a small toss were of great consequence to him. It is the 
mere fact of its presence at all that affects our prognosis so 
much. Hence not the proportion of albumen made visible by 
our tests, but the circumstances accompanying the discovery, 
make that prognosis favorable or the contrary. 



456 ALBUMINURIA. 

■ » 

One very important circumstance is the permanence of the 
symptom. A single experiment should never make you a gloomy 
prophet; for albuminuria is sometimes only of a transitory char- 
acter; and though that single occurrence may lead you to be sus- 
picious and anxious about the future history of the patient's 
kidneys, yet it may be years and years before any harm happens. 

Another thing that you should search for is blood. If there 
is a stain of it in the renal excretion, or if blood-disks are to be 
found by the microscope in the sediment after the specimen has 
stood quiet for half an hour, you will know that the disease has 
not yet lasted very long, and therefore is more likely to be 
transitory than if it were of old date. This observation is of 
great prognostic value after scarlatina. In patients recovering 
from that complaint the absence of blood from albuminous urine 
is a bad sign, as showing that the kidneys were probably un- 
healthy before the accident of the eruptive fever; while the pres- 
ence of blood, as shown by a red or dusky or smoky tinge, is an 
encouraging one. If the urine must be albuminous, it had better 
be bloody, as far as prognosis is concerned. 

The secretion of a great quantity of water in albuminuria is 
some evidence of the chronic character of the ailment, and is 
thus far unfavorable; but this phenomenon is so much varied by 
the daily habits of the patient, the state of the skin, bowels, &c, 
that it is difficult to give any strict rules of prognosis dependent 
thereon. 

The leading fact for you to note in albuminous urine is the 
quantity of solid matter which is daily passed. The quantity of 
solid matter (three-fifths of which is urea) is practically a direct 
measure of the vitality of the secreting portion of the gland from 
whence it comes; and you know that if there is a fair average 
amount of that substance made in the twenty-four hours, there 
is a sufficiency of healthy kidney remaining, however abnormal 
the remainder may be. 

Hence you derive the following rules : 

1. The prognosis is best, if the specific gravity is as high as 
that of healthy urine, and the quantity natural. 

2. It is next best, if the quantity is diminished without dimi- 
nution of the specific gravity. 



ALBUMINUKIA. 457 

3. Next, if the specific gravity is diminished without diminu- 
tion of the quantity. 

4. Worst, if both specific gravity and quantity are diminished 
together. 

In the course of lectures on systematic medicine, I describe 
as in duty bound the many shapes which degenerated kidneys 
assume, the "large yellow," the large and small "mottled," the 
"granular," the "cysted" large and small, the "hard," the 
"atrophied," and whatever other I can find represented by 
specimens in the museum, or sketched in my portfolio. I seldom 
conclude the subject without being asked whether these diverse 
forms are witnesses of diverse noxious agencies — whether some 
arise from one cause and some from, another — whether some im- 
pede one function and some another — above all, whether special 
remedies are needed for each. I am forced in honesty to answer, 
to the best of my belief, No ; and to say further that it is lucky 
it is so, for at present our means of diagnosis do not enable us 
to find out which form lies hid in the body of a sick man. The 
light has failed which it was hoped microscopic research of the 
renal casts might throw upon the matter, and it is only by a 
statistical observation as to which is most usual at particular 
periods of life that a rough guess can be made. We must not 
base our treatment on post-mortal anatomy, or we shall fail in 
our duty to our patient. 

Upon observations of the same phenomena, which form the 
groundwork of our prognosis, should be grounded our thera- 
peutics also. We need not, as a general rule, attend to the pro- 
portion of albumen contained in the specimen of urine examined; 
we must not augment our vigor because the coagulum forms a 
more than usually solid clot ; nor must we consider it less neces- 
sary in a case where we can only obtain indications of the ab- 
normal contents by a slight opalescence insoluble in nitric acid. 
And knowing that the greater or less amount of albumen present 
is rarely of practical importance, let us not waste our time and 
drugs by direct attempts to curb its evacuation. We may, for 
instance, wisely look upon the administration of astringents, such 
as gallic acid given with a view to step the emission of albumen, 
30 



458 ALBUMINURIA. * 

as childish. We know that not the loss of albumen, but the state 
of constitution of •which that loss of albumen gives notice, is the 
real object to be attended to, and to be made the end of medi- 
cation. One runs a great risk of being led off the true track by 
following by-ends. 

What, then, is the essential nature of the state of constitution 
which leads to the presence of albumen? It is an imperfect 
growth, a lower vitalized state of that epithelial cell-tissue which 
separates the effete matters from the blood in the form of urea. 
A portion of these cells remain dead and sticking in the tubuli 
uriniferi, degenerate into fat mixed up with the fibrin derived 
from the blood, and thus replace a pervious gland by a solid and 
obstructive mass. Others, more luckily for the patient, are shed 
in the form of microscopic casts of the tubes. It is obvious that 
the intention of all successful treatment must be to replace them, 
not to prevent their being shed. The patient loses no more by 
getting rid of this useless tissue than is lost by the separation of 
the sequestrum of a dead bone, and it is as bad policy to try and 
avoid one as the other. Indeed, the shedding, in contradistinc- 
tion to the degeneration without shedding, is to be looked upon 
as a thing to be wished, and need raise no alarm, if other circum- 
stances are in the patient's favor. In those cases which recover, 
the casts are often to be found in the urine after the urea has 
regained its normal proportion, and albumen can no longer be 
discovered in it. 

The main object of our treatment should be to restore the 
blood to that sound vital condition which will supply a healthy 
growth of new epithelium equal to carry on the renal functions. 
This is best done by iron. Though I from habit order the tincture 
of the sesquichloride, I am nowise bigoted to that preparation, 
and if any reason can be given for another form of the metal, I 
do not object. The quantity of hydrochloric acid in the salt is 
not sufficient to allow one to attribute any calculable efficiency 
to it; the iron is the essential matter, and the more of it the 
patient can take the better. 

Joined to iron, digitalis seems serviceable. I suppose it must 
act by restoring the balance of the circulation, and so making 



ALBUMINURIA. 459 

the supply of the vital fluid more regular and full. With de- 
generated kidneys there is often joined a like degeneration of 
the heart-muscle, so incipient as not to exhibit alone any symp- 
tom, yet possibly advanced enough to aggravate other existing 
evils. It is in these cases of weak heart, especially with irregular 
pulse, that digitalis is so useful. From 25 to 50 minims of the 
pharmacopoeial tincture daily is enough. 

Strychnine is also a valuable tonic. It may possibly act by 
strengthening the muscular action of the heart. The doses 
should be small; one-twentieth of a grain three times a day is 
enough to begin upon ; but with many patients, to whom the 
drug is especially serviceable, you may often increase it gradu- 
ally to double that dose.* 

There is no physical agent capable of doing so much harm in 
albuminuria as mercury. Its action as a destructive is much 
more rapid in this state of the system than in any other. You 
can almost see the increase of the anaemia under your very eyes. 
In advanced cases of renal degeneration, after one or two doses 
sometimes the gums will show how the tissues are melting away, 
though there is hardly vitality enough to exhibit an increase of 
normal metamorphosis. 

Yet this poisonous reptile carries, like the fabled toad, a jewel 
in its head. Where the specific gravity of the urine, and a quan- 
tity at all approaching the normal, indicate a trustworthy amount 
of metamorphosis, you can use this metamorphosis with most 
powerful effect to remove the dropsies which are so common in 
albuminurias. You may save the patient's life by an agent 
whose full effect is poison to him. 

But remember you are wielding a sledge-hammer. Visit your 
patient between each blow, and watch its action with extreme 
suspicion. Do not let the blows be too frequent — one in the 
twenty-four hours is quite enough. And do not wield it against 
such butterflies as swelled ankles and puffy eyelids, nor on any 
but urgent cases unless you have tried other means first. 

* It may be remarked that the safest form of strychnine is the hydrochlorate 
dissolved in a solution. The dose is the same as that of the alkaloid. It is 
safer made up in a draught than in a pill. 



460 ALBUMINURIA. * 

I have not myself employed any forms of mercury besides the 
bichloride and the blue pill, but I have nothing to say against 
other preparations. I usually give them combined with digitalis, 
and sometimes with squill; that latter drug seems to increase the 
quantity of water and salts in the urine, which are serviceable 
as a vehicle for the urea of metamorphosis. 

Next to mercury, I think alcohol has the most harmful power 
in albuminuria. Theoretically, we may suspect the injury to lie 
in further checking the already wanting metamorphosis of tis- 
sues. As a matter of fact, you will find under its use the skin 
become anasarcous, fluid accumulate in the serous sacs, soaking 
of the lungs, producing dyspnoea and cough, poisoning of the 
brain with ureous blood, indicated by stupidity, giddiness, and 
coma, and, in short, all the evils you most dread in these cases. 
And alcohol has not, like mercury, a virtue which makes you 
overlook its felony. It seems to do nothing but harm in that 
deficiency of life which is the essence of the disease. 

The only reason which can justify you in employing alcohol is, 
that the mind and nervous system of the patient happen to have 
been so long accustomed to its abuse, that when you have fairly 
tried to leave it off they sink from want of it. 

In the last sentence I designedly used the word "abuse" in- 
stead of "use." You may readily distinguish those who have 
exceeded what is good for them in their employment of alcohol 
by this very weakness; they cannot bear to leave it oif when on 
a bed of sickness — the bond-chains are so welded on to the nerv- 
ous tissue, that in tearing them off you tear away life with them. 
Whereas a temperate user, who regulates the quantity of alcohol 
by its benefit to his digestion, and habitually lets the effect of 
each dose go quite off before he takes another, can bear without 
inconvenience to his nerves the removal of his accustomed in- 
dulgente. Be careful to ask your patients if they ever take 
alcoholics in the forenoon or between meals, as, if they do not, 
you need not in general be at all afraid of ordering them entirely 
to abstain. 

A very important item in the treatment of albuminuria is warm 
clothing, especially woolen, next the body. It is not merely the 



ALBUMINURIA. 461 

warmth, but the electric action of the animal fabric which is 
beneficial so the skin. This is much more necessary to be in- 
sisted on than a high temperature in the house, for in fact it is 
not a high but an even temperature that is required, and that is 
best secured through the normal retention of the heat by such 
sort of clothing. 

Dropsy of an extent to require special treatment will scarcely 
ever come on when patients conform to the above treatment. But 
you may find it already existing, as happens with the majority 
of albuminuriacs admitted to hospitals, so that practically you 
have as often to treat it as to prevent it. 

The quantity of water excreted per urinam is defective, and 
hence much good is often done by simple confinement to the 
horizontal position in bed, and the administration of watery 
drinks in greater amount than the thirst demands. Frequent 
doses of weak broth attain that end very well. For water is a 
true restorative diuretic; it increases the amount of fluid se- 
creted to a proportion greater than its own bulk, and it also 
increases the amount of urea and salts, thus directly increasing 
vitality. That niter has the same power is rendered extremely 
probable by the experiments of Parkes and Dr. Shirks (quoted 
by the former*), and I therefore freely administer this neutral 
salt with water in all cases of dropsy. Under the use of these 
means the appetite improves, the lips become redder, and the 
pulse stronger, at the same time that the anasarcous swellings, 
and sometimes even ascites, diminish. 

Warm baths, soured with hydrochloric acid, seem also useful. 
In two chronic cases (mild ones though) the excretion of albumen 
in the urine has disappeared, as well as the dropsy, under their 
employment. But I have never ordered them alone, the patients 
always having iron at the same time; so that I cannot speak 
very positively on the subject, except so far as to say that they 
certainly do no harm, and probably do good. 

While on the subject of baths, I would remark that you must 
be careful not to let them be too hot. " The warmth of the 
body" is doubtless a wise rule, but then the warmth of the body 

* Parkes on the urine. "On the Urine in Health," chap, ii, sect, iv, 8. 



462 ALBUMINURIA. 

in albuniinuriacs is much below that of yours in health, and 98° 
Fahrenheit often produces in them gasping, faintncss, and ex- 
haustion. They bear sudden changes of temperature in the 
direction of heat quite as ill as in the direction of cold, and 92° 
is usually quite high enough for them. 

Hot-air or vapor baths you sometimes see me order. Their 
advantage is that they can be used where the patient is so much 
swollen as to make getting up painful; but the effect is very 
stifling, even though the head is kept out, and is not more pow- 
erful in promoting the action of the skin than water baths. 

It is only when these means have failed that I betake myself 
to mercury, with the fear and trembling above described. 

An occasional active purge of jalap and cream of tartar will 
often be of service by setting up absorption of the extravasated 
fluid back into the veins. It is then thrown off by the kidneys. 
But you cannot trust to purgatives alone even to remove the 
dropsy, and on the albuminuria their influence is to be suspected. 
It is probably harmful, by increasing anaemia. 

Of all purgatives the most weakening is elaterium. Its action 
is a peculiar one: — it causes an enormous flow of watery serum 
from the first mucous membrane that absorbs it: — if its vapor 
be drawn up into the nostrils for a short time, it is a powerful 
errhine, and is followed by a secretion of a pint or more of water 
from the Schneiderian membrane: — if it is dissolved in the 
oesophagus it causes such a deluge of the gastric fluids, that the 
stomach cannot retain them, and they are rejected by vomiting: 
— if it succeeds in passing the pylorus, a choleraic diarrhoea 
gushes forth, stripping the membrane of its epithelium just like 
its morbid prototype. It is therefore very uncertain in its ope- 
ration, and I am sure I have seen patients not only frightened 
but really hurt by it. Moreover, I have never found benefit 
from its use in renal dropsy where jalap and bitartrate of potash 
had failed. If you are steadily purposed to give elaterium, use 
the form of enema, for you thus avoid the vomiting which is so 
apt to arise. 

To puncture the anasarcous skin for the sake of relieving 
temporarily the distention is justifiable where that distention is 



ALBUMINURIA. 463 

causing more harm than a mere inconvenience, as for instance 
in the penis where it impedes the passage of urine, or in the 
scrotum and legs when it threatens to crack or to be frayed into 
sores. It is better to puncture it with a lancet to the depth of 
about a quarter of an inch than with a needle : the slits thus 
made discharge more freely and continuously, and are less likely 
to cause erysipelas than the smaller but more numerous needle 
pricks. I have scarcely ever found any evil result to follow this 
practice, and where the skin and areolar tissue have been very 
tense, I think they have by its means been often preserved from 
sloughing. 

When in dropsy from either albuminuria or diseased heart you 
are unfortunate enough to have a patient's skin slough, I should 
recommend you to employ a lotion found highly efficacious in 
our wards, made of equal parts of glycerin and of water sat- 
urated with chlorate of potash, and to keep the surface carefully 
covered from the air. The rapid restoration of vital action to 
the edges of the mortified tissue under the use of these means 
is very remarkable. 



LECTURE XXXVI. 

ALBUMINURIA. 

Case of albuminuria with vomiting from ague cured — Case of 
albuminuria fatal from sudden pneumonia — Case of albu- 
minuria fatal from epistaxis, and loss of blood and albu- 
men — With comments on each. 

(Clinical, St. Marys, October 31, 1863.) 

Robert H., aged thirteen, was brought by his father to the 
hospital the first week in September. They had both landed 
three days before at Deal, out of a small schooner from Algeria. 
They had been four weeks and a half on the voyage, and during 
the whole of it had nothing to eat but potatoes; for the beef 
taken in store had got putrid. They slept in the life-boat and 
frequently got very wet. The father was taken with quotidian 
ague when about half way over, and this lad had one paroxysm 
on the sea, and one after landing. For this ague he was brought 
in here, was treated with quinine, and had no return of it. It 
was observed, however, that his spleen was large, and he had 
some anasarca during this first residence in the wards. On the 
25th of September he was discharged, and a week afterward the 
anasarca returned in his legs, and the abdomen swelled. He 
was readmitted on October 9, with anasarca of the whole lower 
part of the body. There was fluctuation in the peritoneum on 
percussion, and dullness of its lower portion on both sides. No 
enlargement of the spleen could be detected. The heart sounds 
were normal. The urine was of a dusky-brown color and very 
albuminous. 



ALBUMINURIA. 465 

On the 10th he was ordered this draught — 

3^ Tincturw ferri sesquichloridi, H|xv, 
Pot ass x nitratis, gr. xv, 
Misturse camphor de, 5j, 

ter die, 
and a hot-air bath every night. 

Then occurred a symptom which is not uncommon in albuminuria, 
namely, vomiting. He felt constant nausea, and threw up the 
contents of the stomach several times daily. But in spite of this 
the anasarca disappeared, and the greater part of the fluid was 
absorbed from the peritoneal sac. But yet it struck me that 
the medicine might have had something to do with the sickness. 
So I left it off once and again, and both times the inconvenience 
ceased. 

But I did not like foregoing the use of iron altogether, so I 
have since the 24th kept him on an ounce of mistura ferri three 
times a day. That he bears well and profits by. There are no 
signs of anasarca or ascites; and what is of more happy augury 
still, the albumen no longer is to be found in the urine, which is 
of normal color and acidity, and 1015 in specific gravity. He 
remains in the hospital only because his father cannot for a few 
days return from the country to fetch him home. 

The only peculiarity in this case is the vomiting, which, how- 
ever, as here, you may often by experiment trace to some un- 
suitable article in the medicine or food. Where you cannot 
find any such cause, and it continues obstinate, I have found 
alkaline effervescing draughts the most effectual remedy in albu- 
minuriacs. 



(St. Marys, October 26, 1863.) 

I show you here the kidneys just taken from the body of a 
man who was yesterday brought into the hospital dead. He had 
been long a delicate man, but able to do a fair stroke of work. 
Two days before he had come as a casualty patient to the house 
surgeon, who found him suffering from a certain amount of pneu- 



466 ALBUMINURIA* 

monia and catarrh, but was unable to admit him as an in-patient 
on account of the fullness of the wards. The next day he was 
worse, but still got up. On the morning he died, a man came 
and said he was very ill indeed, and obtained a promise of a bed 
for him. Before he got to it he had expired. 

On examination, it was found that at most a quarter, I should 
have said not so much, of the right lung was imperfectly con- 
densed with recent inflammation. The rest of the pulmonary 
tissue on that side and the whole left lung was free from con- 
gestion, though wet. We began to wonder at the man's death 
from so insignificant a cause ; for we are not used to have pneu- 
monic patients die, without the pneumonia being either double, 
or at least occupying the whole of one lung. The heart too was 
quite uninjured. But the mystery was cleared up when we 
opened the abdomen and found the kidneys I show you. 

On tearing off the capsule you see that it adheres much closer 
than it should do, and that when it is gone, the surface of the 
organs is coarsely granular, instead of being smooth and shining. 
And a section exhibits the tubular and cortical structures much 
less distinct and different than natural. It looks as if some 
dull flesh-colored or tawny stuff had been mixed up in both of 
them. Truly there is nothing here very conspicuous to students 
on the remoter benches of the theater ; but still, if you examine 
the parts in your own hands, you will see a good deal abnormal; 
and if you apply your minds you will see more still. You will 
see that there is much here which should not be, and yet that 
the kidneys are anything but increased in size. There must, 
therefore, be a serious loss or destruction of the important secret- 
ing structure of the organ. It is in point of fact not absolutely 
destroyed and removed, but it is partially devitalized into a less 
organized substance, which is utterly incapable of performing 
the duties of separating the urea from the blood, and of retain- 
ing the albumen in the blood-vessels. Hence the importance of 
lesions of the kidneys. And hence their importance is in direct 
proportion to the amount of secreting substance partially killed; 
not at all in proportion to their conspicuousness, and to the show 
they may make in the hands of an artist of morbid anatomy. An 



ALBUMINURIA. 467 

abscess, or a stone, or an hydatid, may be more capable of artistic 
development, but they are by no means so important in their in- 
fluence on health as a Bright's kidney so little apparent as to be 
easily passed over by a careless dissector. 

I say the patient's rapid death was explained by the degen- 
eration of his kidneys. But I do not by any means intend to 
imply that he died of the renal disease. On the contrary, I 
bring this case forward especially to show you that it is not 
necessarily a fatal lesion. This man had lived with it probably 
for years, and gained his livelihood, and might have continued 
to live and gain his livelihood for an indefinite period. It was 
no recent or sudden increase of the long-standing visceral lesion 
which caused death, but the addition to it of a slight pneumonia, 
due to external causes, and very far from sufficient in itself to 
kill. 

Both of these facts are highly important and suggestive : the 
first showing that a patient with degenerated kidneys and albu- 
minuria may live, to a certain extent enjoy life, and be an useful 
member of society ; and the second, that if insignificant inflam- 
mations are added, they may very possibly prove rapidly fatal. 
Both facts should encourage us to spare no pains in preserving 
the health of our albuminuriacs, in the well-grounded hope that 
such pains will not be thrown away. 

(Clinical, St. Marys, December 12, 1863.) 

You have often heard me say that the amount of albumen con- 
tained in the urine of those affected by Bright's disease, is a 
matter of no practical moment; and I have corrected you when 
you have anticipated evil results to a patient, because the quan- 
tity exhibited by boiling and nitric acid chanced to be unusually 
large, or when you have slurred over the serious import of find- 
ing some slight traces of its presence in other instances. The 
fact is, that the loss of albumen is easily replaced by food. Con- 
sider that 100 parts of meat contain from 15 to 20 parts of pro- 
teine, which are converted by digestion into a soluble form of 
albumen and pass directly into the blood ; and, consequently, a 



468 ALBUMINURIA. 

daily loss of 10 grammes of albumen may, if the digestion is 
fair, be replaced by three ounces of meat taken as food.* And, 
as a matter of fact, it usually is so replaced in our hospital pa- 
tients, whose anaemia hardly ever increases while in the wards. 

Yet exceptional cases do occur, to one of which I have to call 
your attention to-day. Michael B., aged twenty-two, of a marked 
leucophlegmatic temperament, with pale blue eyes and yellow 
hair, a new patient on November 27, stated that he had con- 
tinued well and able to work as an ostler till four weeks before 
that date, when he was taken with vomiting, rigors, prostration, 
sore-throat, and feverishness, and was forced to lay up in his 
miserable lodging-house. He could not remember that he or 
anybody else had observed any eruption of the skin ; yet I can- 
not but think that this feverish attack was scarlatina ; for after 
four days' illness his face and legs began to swell, and anasarca 
continued up to the time of his coming under treatment, when 
the ankles, thighs, and abdominal parietes all pitted on pressure. 
At the same time that he became dropsical he began to suffer 
from pain in the loins, and he observed his urine to be frequently 
bloody — indeed more often bloody than not. He had suffered 
also from bleeding at the nose, and from vomiting. His respira- 
tion during the previous week had become short and difficult when 
he lay down in bed, so that he had to sit up, and snorted and 
snored a great deal in breathing, often also gasping for breath 
and sighing. 

He was sent to bed and cupped to eight ounces on the loins. 
Sesquichloride of iron and tincture of digitalis were at the same 
time prescribed for him. This treatment was commenced im- 
mediately, and perhaps it was in consequence of it that we never 
saw the urine bloody, and that he had no more pain in the back. 
At all events such was the fact. But though there was no blood 
in it the urine contained an unusually enormous quantity of 
albumen, some specimens coagulating by heat nearly into a 
gelatinous mass. It was copious, light colored, and of a specific 
gravity always below 1015. A drop of blood drawn from a 
needle prick of the finger was very pale, and placed under the 

* Vogel on "Quantitative tests of albumen." 



ALBUMINURIA. 469 

microscope exhibited a deficient number of red disks in propor- 
tion to the white globules, which latter were in comparative ex- 
cess ; and there was a considerable abnormal quantity of the 
fine granules in the serum. Many of the red disks had also fine 
granular specks in them as if degenerating, and quickly became 
crenated at the edges; they however formed into rolls in the 
natural fashion. 

On the 28th he had some epistaxis, and several times threw up 
his food. In it there were some masses of mucus stained with 
blood, but wdiether these came from the stomach itself or from 
the nose could not be rightly determined. 

By the 2d of December the anasarca had quite disappeared. 
But the patient still breathed noisily, irregularly, and quickly, 
and gasped often like a person exhausted by loss of blood. The 
uvula was much relaxed, hanging down on the top of the glottis, 
and he coughed frequently and spoke in a whisper. 

On the 4th he got up and moved about the ward a little, but 
was terribly exhausted by the exertion. 

On the 5th the epistaxis had become more frequent, but was 
very small in quantity at a time. It little more than just stained 
the handkerchief, so pale was his blood. The enormous quantity 
of albumen lost by the kidneys was unabated, but he kept down 
more food. On account of the epistaxis I ordered him 3j of 
gallic acid three times a- day. 

On the 6th I found him sinking. The countenance was ex- 
cessively anxious, he was throwing his arms about in an agitated 
manner, gasping and sighing and complaining of pain all over, 
especially at the epigastrium. His tongue got dry and yellow, 
sordes collected on the teeth. But his mind was perfectly clear, 
and seems to have remained so till his death next day. 

The case will of course be entered in the register as one of 
" dropsy," for with that disease he was received into the hos- 
pital ; but yet he did not die of dropsy, either in the form of 
anasarca, hydrothorax, oedema pulmonum, effusion on the brain, 
or of any of the kinds of local congestion which conclude nearly 
every renal degeneration. Altogether, his end resembled that 
of one killed by long haemorrhage. And in truth that may be 



470 ALBUMINURIA 

said to have been the" manner of it. For though latterly there 
was scarce any appearance of red blood in what he lost, yet 
what he lost was a part of the blood next in importance to the 
red constituents ; while at the same time the state of his stomach 
prevented the drain of albumen passing away from being re- 
placed. 

The case is very different from one of ursemic poisoning ; it 
is the albuminuria, the loss of constructive material, and not the 
uraemia or retention of injurious material, which has killed the 
patient. There was none of the coma, or merciful overclouding 
of mental perception, which is the usual end in Bright's disease ; 
but on the contrary extreme sensitiveness and agitation. I rejoice 
to think that such a termination is rare, for it is most painful to 
witness. 

But for all that there is no doubt of the kidneys being ex- 
tensively disorganized by some form of Bright's disease, and 
considering his age and the rapidity of the fatal result I should 
rather expect to find at the post- mortem examination you are 
going to see, a specimen of the large yellow smooth kidney.* 
How long he has had it none can tell ; but it cannot have been 
long, for he was not injured by it till the scarlet fever (as I 
suppose) added its renal congestive influence to a pre-existent 
lesion. 

I drew your attention to his leucophlegmatic crasis. Now, I 
am far from wishing you to put faith in all the vagaries built 
upon the doctrine of temperaments, as you know well from my 
systematic course on the practice of medicine. But yet I cannot 
shut my eyes to the fact, that there are certain forms of internal 
constitution, which, when they exist in a marked degree, do de- 
clare themselves by the external appearance and features, and 
that it is not entirely devoid of practical utility to take heed to 
these external features in regulating our treatment. Of these 

* It was rash to have dared so publicly to predict the form of degeneration, 
as the account of the dissection extracted from the " Post-mortem Record" 
shows. But I certainly did expect it, and it would be scarce honest to omit 
this sentence. It will at all events serve as a warning to clinical lecturers not 
to be over-precise in their predictions. 



ALBUMINURIA. 471 

classes of constitutions one of the most important in respect of 
our practice is the leucophlegmatic. This is not the place or 
time to paint its peculiarities, which has been done so often by 
more graphic artists than I can hope to be. But all agree in con- 
trasting it with the sanguine, and making, in short, these two 
temperaments antithetical to one another as to all their habitual 
phenomena. Now, it has always struck me that the most im- 
portant antithesis between them is one not usually brought for- 
ward, or at least only indirectly alluded to. I mean the relation 
which they bear to degenerative disease. In the sanguine tem- 
perament febrile disease is short, violent, and soon ended — cito 
mors venit, aut victoria laeta — while degenerative disease is slow 
in progress, slightly marked in its phenomena, and little affected 
for better or for worse by remedies. In the leucophlegmatic 
temperament febrile disease is sluggish in progress, and im- 
perfectly marked in its characters ; while degenerative disease 
is extremely rapid, strongly marked, and either quickly fatal or 
freely amenable to remedies. It has been, as you have witnessed, 
rapidly fatal in the patient who is the text of this lecture ; but I 
have often pointed it out to you checked with equal rapidity in 
more fortunate leucophlegmatic subjects. The observation, there- 
fore, of the temperament affects both our prognosis and our 
treatment. 

[Extract from Record of post-mortem examination by Mr. Nayler, Curator to St 
Mary's Hospital Museum. 

Examination five days after death. — The kidneys were of small size, weighing 
respectively only one and a half and two ounces ; they were studded with small 
cysts varying from a millet-seed to a pea in diameter. They were pale and 
mottled externally and the capsule was readily detached. The lungs were very 
pale, but otherwise healthy and expansible. There was a good deal of blood- 
stained fluid in both pleura. (The blood- stain of the effused fluid, and some 
other phenomena not necessary to notice here, were probably caused by the 
length of time which was unavoidably allowed to elapse between the death and 
the autopsy.— T. K. C.)] 



LECTURE XXXVII. 

ASCITES. 

Part I. — Case of ascites from hepatic degeneration relapsing 
after tapping several times prevented from returning by the 
use of iron — Cause of the disease irremovable, get the dis- 
ease capable of cure — Pathology of ascites, and connection 
of the treatment with that pathology. . 

Part II. — Case of ascites from renal degeneration treated with 
iron and cured, though the albuminuria remains as before — 
Contrast of this with two cases of albuminuria from a 
remediable cause. 

Part I. — (Clinical, St. Mary's, January 16, 1863.) 

William S., aged thirty-four, though he himself denies having 
lived an intemperate life, receives a different character from his 
brother, who says he has, at various periods, drank hard, and 
that even when not indulging in drunkenness, he has been in 
the habit of taking drams and beer between meals, and has kept 
himself in consequence in a low position in the social scale. The 
patient says that the only illness different from the present he 
has ever suffered from is rheumatism without swelling (chronic 
rheumatism or rheumatic gout), with which he was laid up 
twelve years ago. Two years ago his friends noticed that his 
complexion became jaundiced, and a year ago his abdomen 
swelled, for which he was in St. George's Hospital for five weeks, 
and went out somewhat relieved. He then drank green broom 
tea, and got much smaller in consequence. In August, however, 
he swelled again much larger than before, and at the end of Oc- 
tober was so large that his surgeon tapped him, and drew off a 



ASCITES. 473 

large quantity of fluid. Immediately however he swelled again 
bigger than ever, and on admission at St. Mary's, November 18, 
1862, he was so ascitic that he could not stand ; the breathing 
was much interfered with, and there was some anasarca of the 
legs. Tapping was accordingly again resorted to, and the 
quantity drawn away amounted to a few ounces over four gallons 
of clear fluid. At the same time, as the urine did not exceed 
about half a pint in the twenty-four hours, he was ordered the 
following diuretics : 

3^ Pil. hydrargyria 
Scillse pulveris, 
Digitalis pulveris, aa gr. ij, 

omni node et mane. 
Infusi scoparii, Siij, 
Sps. wtheris nitrici, W\xx, 
JEtheris chlorici, Tt]x, 

quartd qudque hord. 

But in six days he was quite as full of water again as ever, 
the abdomen was distended and painful, there was pain in taking 
food into the stomach, and it was often vomited up again. The 
urine too remained excessively scanty, depositing a copious 
orange-colored precipitate. Elaterium was then given in ad- 
dition, but with no beneficial effect, either when administered in 
enema or by the mouth. He took it for ten days, and then was 
seen to be growing gradually larger and more incapable of 
motion. On December 10 you may see that all his former 
remedies were left off, and he was treated with the following 
draught three times a day : 

Tincturse ferri sesquichloridi, W\xx, 
Potassse nitratis, gr. xv, 
Misturse camphor w, oj- 

He very soon began to improve. His appetite returned, and 
on the 25th he was able to get up, dress himself, and be about 
in the ward. His abdomen ceased to increase, indeed was an 
31 



474 ASCITES. * 

inch or so less in girth than before the change of medicine. But 
here it was stationary, so on the 31st I persuaded him to be 
tapped again ; nineteen pints of fluid were drawn off, when it 
ceased to flow, and some was apparently left in the peritoneum. 
Since then he has not again swelled, the bowels are regular and 
the appetite good. A fortnight after the tapping I find the 
clinical clerk has noted that he has got smaller in girth, and 
that he makes a pint of urine every night and a good deal during 
the day. This increase in the action of the kidneys has been 
gradual and did not immediately follow the last tapping. The 
patient is so impressed with the source of his disorder being 
traceable to alcoholic drinks, that he asked to have an egg daily 
in place of some ale which had been allowed him. 

This case is a typical instance of the very common history of 
continual indulgence in depraved tastes. The constant presence 
of alcohol in the blood obstructs the necessary renewal of the 
fibrous capsule of the liver ; contraction of the degenerated tissue 
ensues ; the portal blood cannot pass through the viscus, to get 
rid of its effete particles or to bear the nutriment to the general 
circulation ; the natural halitus of the peritoneal sac cannot be 
reabsorbed, and therefore accumulates to form an ascitic (or, as 
the Greek word means, an " ensacked") collection of serum. 
With this fluid is mixed also the albuminous serum and fibrous 
serum which exudes from the obstructed capillaries, and often 
these capillaries rupture and blood-corpuscles are found in the 
dropsical fluid. 

Observe that in such cases as these, of which William S. is a 
strongly-marked example, we have permanently fixed in the body 
a constant source of disease, a deformity of an important organ 
which is absolutely incapable of being replaced. The patient's 
liver is indubitably the cause of disease ; if we could see it we 
should probably find it puckered up and scarred with hard con- 
tracting fibrous tissue, compressing and causing atrophy of the 
secreting structure. The majority of the hepatic cells are prob- 
ably dead and converted into or filled with fat ; and there is not 
room for new cells to grow. You can no more cure this, than 
you can cure the hard useless scar of a burn. It is not the dis- 



ASCITES. 475 

ease. The disease is its consequences, the ascites, the anasarca, 
the diminished urinary secretion, the jaundice, the anaemia, the 
general discomfort under which the man labors. These are ca- 
pable of very decided alleviation and often of cure. You may 
look at the matter in this light — you have a patient whose body 
is deformed by a deficiency of liver ; and as you are unable to 
give him back a liver, your aim must be to give him back those 
functions and those constituents of the body which the wanting 
organ has ceased to supply. 

Remark what happened when the ascites was treated merely 
as a foreign body, as a thorn in the flesh to be plucked out. The 
quantity and weight of the fluid was a very painful burden to 
him ; it entirely prevented his getting up, pressed on the stomach, 
produced vomiting, and seemed to the patient to leave no room 
for his meals. So there was a reason for its removal by tapping. 
But he immediately swelled again as large as ever, if not larger, 
on the two first applications of this process. And during this 
period the most powerful diuretics were vainly directed to in- 
crease the action of the kidneys. He himself felt strongly the 
failure, and declared that it should never be done again. 

See, however, the effect of a three weeks' course of iron. He 
recovered strength so far as to remain sitting up in the ward a 
great part of the day ; although the abdomen was as large as at 
first and much impeded motion, his muscular power enabled him 
to walk about; he gained flesh and some color in his cheeks. 
Then was the time for tapping to be effectual, and with some 
trouble we persuaded him to retract his resolve and to submit 
again to what he justly enough urged had failed before. A con- 
siderable portion of the fluid was drawn off, and that amount 
which was removed has not again accumulated. He continues 
to get smaller in girth daily, and I hope in two or three weeks 
will be fit to leave the hospital. 

The rationale of his improved condition is that the iron has 
restored the blood to its natural state, and thus supplied to the 
tissues that which is the final end of nearly all our manipulations 
with pharmacopoeias and with nursing — namely, healthy nutri- 
ment. Without this, treatment would be utterly useless ; with 



476 ASCITES. * 

it, you see a rough treatment, namely, tapping, which had been 
unsuccessful once and again wider previous circumstances, has 
now led to a happy result. Can we refuse to recognize this as 
true restoration, as real cure ? 

I am sorry to say it has been impossible entirely to keep his 
old habitual poison from him. His spirits and nervous system 
generally got so low that it was necessary to allow him some gin 
daily. I am gradually diminishing his allowance, but I fear that 
when he gets out of our sight he will not be able to refrain. 
This of course must keep up, even if it does not increase, the 
degeneration of the hepatic tissues, and very slight accidents will 
readily bring back his dropsy. But so far as he is restorable, I 
think you have learnt the way to restore him. 

The pathology of ascites I presume to be this — from obstruc- 
tion of the liver, either temporary, of which you have one ex- 
ample in diseases of the heart, or permanent, as in degeneration 
of the hepatic tissue itself, or in compression of it by malignant 
tumors and the like, the passage of blood through it is hindered. 
This imperfectly vitalized blood insufficiently nourishes the ves- 
sels of the peritoneum, which consequently become inelastic and 
more ready even than they should be to part with their watery 
contents by exosmosis. At the same time the sluggish move- 
ment of the circulating fluid retards absorption, according to the 
well-known law of osmosis that, in the case of a fluid set in mo- 
tion, it is rapid in a direct ratio to that motion. Thus you have 
a double reason for the collection of the fluid, increased exos- 
mosis from the blood and diminished endosmosis into it. 

Rational treatment makes its chief aim the remedying, as far 
as remediable, such a state of things. It aims at restoring the 
strength and elasticity of the abdominal capillaries, at quickening 
and vitalizing the circulating blood, and thus renewing absorp- 
tion to its normal activity. Normal activity ! No slight thing 
is this we are speaking of: remember Dr. Richardson's experi- 
ment, by which he showed that fluid equal to at least one-sixth 
of an animal's whole weight may be absorbed by the peritoneum 
in twelve hours;* and then consider that if a man's peritoneum 

* See the previous Lecture on Hydrothorax, page 220. 



ASCITES. 477 

can work at an equal rate (as I dare saj it can) he will be able 
to dispose of at least a couple of gallons in the same time. So that 
if you can secure anything like a normal activity, you will soon 
do away with the ascites. Look upon it as a collection dependent 
on deficient vitality, not as an effusion dependent on some imag- 
inary increased activity, and your treatment has a better chance 
of being rational and successful. 

You will perhaps say that I was inconsistent in not trusting 
wholly to the iron, and that tapping ought to have been need- 
less. But the fact is that, after long soaking with the ascitic 
fluid, the tissues are so saturated with it that they can return 
to their allegiance very slowly ; and that the process is much 
hastened by removing the already collected serum. After the 
operation indeed you may give the iron with safe confidence, 
and your confidence will often be justified by a similar success 
to that which has attended this case. 



Part II.— {Clinical, St. Marys, July 25, 1863.) 

Dennis S. has been under your observation since June 12. 
His age is sixty, and his employment that of a costermonger. I 
have no reason to doubt his statement that he has been always a 
sober and temperate man, but of course in his trade he has been 
a good deal exposed to inclement weather. Two years ago he 
was knocked down by a cart, which passed over his loins; and 
during the illness which followed there was blood in his urine, 
and he was told by the physician who attended him that his 
kidneys were injured. After that he recovered health, and was 
well till last March, when he felt ill, and had cold skin and fre- 
quent shiverings. Soon his legs began to swell, and he had 
looseness of bowels, amounting sometimes to diarrhoea, after 
eating. He had also much cough, accompanied by thin mucous 
expectoration. In May the belly began to swell, and he lost his 
complexion, becoming of a pale faded-leaf color. 

When first I saw him in bed there was very considerable ana- 
sarca of the legs and ascites of the abdomen. But a couple of 
days' confinement to bed took away all the swelling of the lower 



478 ASCITES. 

extremities, leaving the ascites as the marked feature of the case. 
He measured forty inches round at the level of the navel, and 
the dullness on percussion caused by the fluid rose to within four 
inches of the mesian line. His urine was light colored, copious, 
of specific gravity from 1*010 to 1*015, and very albuminous. 
There could be found in it sometimes granular, sometimes smooth 
casts of the tubes. 

He was ordered 1T[xx of the tincture of the sesquichloride of 
iron four times a day, and had hot-air baths* at night. 

On June 24 he measured thirty-eight inches round, and on the 
26th thirty-seven inches. 

I must remark that this measurement did not fairly represent 
the total diminution of fluid. For the abdomen was very reso- 
nant in places where it had previously been dull. In fact the 
vacant space left by the serum absorbed from the cavity of the 
peritoneum had been occupied by ilia and colon blown up with 
wind. Do not forget this in your estimate of the decrease of 
ascites — the intestinal walls, from being so long soaked in half- 
dead serum, lose their contractility and become distended with 
flatus ; and thus the mere circumference does not show how much 
fluid is in the sac. You must correct your reckoning by the ex- 
tent of dullness. 

To replace the lost contractility I added Jo °f a grain of hy- 
drochlorate of strychnia to each dose of iron. I find no drug so 
powerful as this to restore that deficient muscular force which is 
shown in flatus of the ilia. And while I am on the subject I 
would give you a hint that you have no need to be alarmed at a 
few twitches or cramps or at a slight stiffness of the jaw arising 
in patients who are taking it; the healthy muscles, the muscles 
you do not care to affect, are affected first in many cases; should 
this happen, all you have to do is to leave off the medicine for a 
day, and then begin it again in somewhat smaller doses. Do not 
leave it off altogether. I have never seen the slightest real harm 
done by strychnine, though it is a favorite remedy of mine. The 
notion of its "accumulating" in the body seems to be a fallacy 

* I have omitted to note when the baths were left off, but I think he had only 
five or six ; as they were ordered in consequence of the anasarca. 



ASCITES. 479 

derived from its occasionally acting more visibly as the patient 
nears health. 

On June 26 his girth was thirty- seven inches, and continued 
steadily to decrease; so that on July 15 (if not before) his belly 
was soft and lax, and of its natural size, as tested by the waist- 
band of his former trousers, namely thirty-two inches. This 
represents the absorption of from three pints to half a gallon of 
serum. 

He left the hospital yesterday in sufficiently good case to re- 
sume his trade, at least for the summer. For along with the 
anasarca and ascites the cough, arising from a dropsical state 
of the pulmonary tissue, has got well. But the urine is still 
albuminous. 

The last example of ascites upon which I gave a clinical lec- 
ture,* was one arising from degenerated liver. On William S.'s 
return from Walton, six weeks after he left St. Mary's, he pro- 
fessed to be quite well, and to be convinced of the importance of 
temperance and iron to keep him so. I hope he is sincere. 

The present example arises principally from degenerated kid- 
neys, of which the diseased urine (albuminuria) affords evidence. 
Degeneration of these organs is usually due to exposure to 
weather, and is no proof at all of indulgence in alcohol. I am 
disposed fully to credit this man's statement that he has lived 
temperately. 

Whether he has not also some slight degeneration of the 
hepatic substance, I cannot say. Very possibly he has, to 
judge by the ascites being such a marked feature in his case. 
For where the kidneys alone are at fault, anasarca is usually 
the prominent disease. But where some other organ fails also 
in a minor degree, such as the lungs, or the brain, or the liver 
for instance, then the joint influence of the two deficiences ap- 
pears in that quarter, in the shape of hydrothorax, or apoplexy, 
or (as here) of ascites. 

Whatever the anatomical cause of the disease may be, it has 
been cured by iron, rest, good food, and strychnine. We may 

* Viz., that of January 16, 1863, which begins this Lecture. 



480 ASCITES. * 

take for granted that his kidneys are as degenerated as ever ; 
but he may be freed from disease, and may keep free from dis- 
ease if he can get the wherewithal, and possibly attain his three- 
score years and ten. 

I want you to understand that what you have to treat is the 
ascites or the anasarca, as the case may be, and not the liver or 
the kidneys. Without the help of, or with the very imperfect 
help of the liver and the kidneys, you have got to restore to the 
blood-vessels that defective elasticity, and to the blood that de- 
fective composition, for want of which the balance of endosmosis 
and exosmosis is reversed. I have already told you how iron 
does this. 

In medicine you have often thus to cure the wound with the 
bullet still in, to relieve the burn with the fire still scorching it; 
for the bullet and the fire are parts of the body itself and cannot 
be extracted. 

But it is not always so in cases of dropsy from albuminuria. 
You have two proofs to the contrary, which have been close 
neighbors to the ascitic patient in the same ward — two little 
boys, each six years old, who were admitted with dropsy and 
albuminuria, the one (Michael K.) on July 3, and the other 
(Walter P.) on July 7. In both of them not only has the dropsy 
got well, but the urine has ceased to be albuminous. Why? 
because it arose from a temporary not a permanent cause, from 
a congestion of the kidneys which can pass away. In one lad's 
case there was a clear account of scarlatina, for some of our 
house surgeons had seen it; and, though the mother of the other 
denied that it had had any cutaneous eruption, yet she admitted 
that she was always out charing all day ; and she brought her 
child here in such a filthy, lousy plight, that I do not think she 
could have looked much at its skin. There was an abscess also 
in one of the tonsils, and that combined with the dusky color 
of the urine assured me that it was an instance of scarlatinous 
dropsy as well as the other, and encouraged me to give a favor- 
able prognosis. 

I said the "dusky color of the urine" encouraged me. In 
fact, that showed me that at least a part of the obstruction of 



ASCITES. 481 

the renal tissue was due to blood, which may be expected to 
move on; and not, as in the old man's case, to a degenerate 
solid, which is an immovable impediment. You may remember 
the porter showing some of us a few weeks ago a kidney which 
he had taken from a patient, whose death he said arose from 
scarlatina. At all events, what he showed us presented in a 
marked degree the character of a scarlatinous kidney. The 
medullary cones were clear and pale toward their apices, indeed, 
paler than usual ; but their bases had a dark blood-red halo of 
intense congestion, rendered more conspicuous by the natural 
color of the rest of the cortical substance. They looked like 
flesh-colored fans, whose broad ends had been soaked in red wine 
lees. Such a state of congestion as this is perfectly curable; 
and, without there should be any evidence to the contrary, any 
previous illness or the like, this is the state you should assume 
to exist in albuminuria after or during scarlatina. This is the 
state which you see me endeavor to prevent in scarlatina, by 
keeping the patients from cold chills (after the skin has been 
cooled by sponging), and by giving them a dose of castor oil 
every morning. A treatment which will, indeed, as a rule, pre- 
vent scarlatinous dropsy, but of course will not cure it when once 
began. 

Both of these children had the same treatment as the old man, 
hot-air baths and iron. Walter P., in whom the scarlatina was 
the most certain and most recent, and who seemed to experience 
some uncomfortable feeling in his back which he was too young 
to describe, had also four leeches and a poultice applied to the 
loins; the reason for which I have sufficiently pointed at by my 
sketch of the morbid anatomy of the disease. The happy result 
which has followed is that which usually rewards our efforts in 
cases of scarlatinous dropsy, if no previous degeneration has 
existed. 



LECTURE XXXVIII. 

DIABETES. 

Case of diabetes, with history of the treatment adopted — Arrest 
of function of construction in diabetes — Saccharine diet 
wasteful and harmful — Test of treatment is gain of flesh — 
Patients to be made into carnivorous animals — Sugar may 
be formed from flesh diet, or from hepatic tissue — But from 
dead, not live tissue- — How far a very strict dietary should 
be enforced — Opium — Cinchona — Iron — Iodide of potas- 
sium — Gratification of thirst. 

(Clinical, St. Marys, July 19, 1862.) 

We know so little of the pathology of diabetes, that it is easy 
to fill a volume with the discussion of the subject; for you will 
observe that talk is always in an inverse quantity to practical 
knowledge. I shall cite only that which bears on a case before us. 

William S., aged twenty-two, a thin, whiskerless and young- 
looking farm laborer, has suffered for at least two years ailments 
of various kinds, which are usually held by pathologists to be 
symptomatic of diabetes. He has been weak and unequal to 
labor, felt always thirsty and usually hungry, and daily voided 
large quantities of urine. For the last year he has been unable 
to work at all from general debility, and on that account came 
into St. Mary's May 31, at which time the above-named symp- 
toms were noted. The chest was examined and found healthy, 
the pulse was slow and regular, the bowels acted daily. The 
skin was naturally moist, and he stated that at night he often 
perspired ; but the sleep was sound, except when he was awakened 
by the bladder getting full of urine. His weight was 6 st. 11J 



DIABETES. 483 

lbs. He remained in hospital five weeks, during which period 
the following variations in the urinary symptoms, with the 
changes in weight during the corresponding time, and the alter- 
ations in treatment to which I trace these changes, are noted in 
a table condensed from the case-book. # 

During the first week the total quantity of urine 

passed was ....... AS 680 

Of the specific gravity before fermentation . 1*042 

" " after fermentation . . 1-012 

His weight had increased to 6 st. 12 lbs. 
During the second week the total quantity of urine 

passed was ....... $5 449 

Of the specific gravity before fermentation from 1*039 to 1*040 

His weight had decreased to 6 st. 11J lbs. 

During the third week the total quantity of urine 

passed was . . . . . . flo 472 

Specific gravity 1*039 to 1*041 

His weight had increased to 6 st. 13 lbs. 

During the fourth week the total quantity of urine 

passed was ..*.... AS 452 

Specific gravity 1*040 to 1*042 

His weight had increased to 6 st. 13J- lbs. 

During the fifth week he lost half a pound in weight, and then 
left the hospital by his own desire. 



During the first week he was treated with a grain of opium 
every night, a mutton-chop for breakfast, in addition to the 
ordinary full diet, with three captain's biscuits in place of bread, 
daily. 

During the second week the opium was left off, and the treat- 
ment altered to eight grains of iodide of potassium three times a 
day, with a drachm of cod oil; he was allowed but one captain's 
biscuit daily instead of bread, but as much meat as he could eat 
and as much milk as he could drink. 



484 DIABETES. * 

During the third week the captain's biscuit was changed to bran 
biscuit ; but in point of fact he did not eat that substance, pre- 
ferring to go without bread-stuffs altogether. No other change 
was made. 

During the fourth week no change was made. 

In the fifth week we tried to persuade him to eat Bouchardat's 
gluten bread toasted and buttered, but in vain. 



The first practical point to be observed in the pathology of 
diabetes mellitus is the arrest in the function of construction. 

That generally used material of nutrition, sugar, which ought 
to be assimilated as food and made available to the growth of the 
body, passes into the thoroughfare of the circulation and out 
again unaltered, and is ejected in the urine. And here I refer 
not only to the sugar which is taken as such into the mouth, but 
also to that which is formed out of starch by the action of the 
saliva. So that in one thoroughly diabetic the whole of the sac- 
charine and amylaceous matters in the dietary are utterly wasted. 
Trying to feed him upon them would be just the same as feeding 
him upon nothing at all. 

More than this, I think you are doing him harm. These 
useless articles of food, though they contribute nothing to his 
support, destroy his appetite, and so he does not eat the needful 
quantity of really nourishing things. And moreover, the analogy 
of other diseases would lead to the conclusion that burdening a 
disabled function with work to which it is unequal will disable it 
more and more. If the stomach rejects undigested an ounce of 
beef, it is made worse by the administration of a steak. If the 
eyesight fails, or the brain reels on slight exertion, common ex- 
perience forbids us to demand violent efforts. 

Therefore you need not wonder to find that cutting off a dia- 
betic's sugar, bread, and potatoes, by no means lowers him. On 
the contrary, he often gets heavier under the restriction. And 
one can easily believe the instances recorded by Dr. Pavy where 
treacle, honey, and sugar, intentionally administered as an ex- 



DIABETES. 485 

periment to diabetics, made the patients feel worse and lose 
weight. 

I do not mention in evidence or rate of any importance the 
increase or diminution of sugar in the excretions, undejj the in- 
fluence of saccharine or non-saccharine diet. It is less when 
little starch and sugar are taken, it is more when much is taken. 
But the real point is the acquirement of flesh, and the test the 
addition of weight. You will find, when the ordinary mixed food 
of healthy men is used by diabetics, that much flesh is lost, and 
that it is regained when a carnivorous dietary is rigidly enforced 
on them. With the flesh also comes strength, showing that 
muscle is gained, and not mere fat. 

The great point then, in the treatment of diabetes, is to accus- 
tom the patient gradually to live entirely on meat, or at least 
entirely on albuminous and gelatinous food. This need not seem 
a mighty hardship ; the iron framed Esquimaux do it, and the 
wiry, tough, half-breeds of the Pampas, with a bill of fare cer- 
tainly less varied in flesh-meat than our European meadows 
afford. You may then fairly direct your energies to attain this 
goal with a good chance of success. What nations live and in- 
crease upon may be trusted to nourish a single individual. 

Laying this down as the main point in the treatment, let us 
see what is likely to be gained by it. 

You will learn from the history of our present patient that 
turning him into a carnivorous animal does not entirely remove 
a diabetic's peculiar ailment. Twenty days after all vegetable 
matters had been cut off from his diet-card, and he has been 
carefully watched by others set to detect any breach of the rules, 
still the urine is full of sugar. So that it must be derived from 
some other quarter than the starchy and saccharine constituents 
of the food. 

We shall feel less surprise at this formation of sugar from 
animal matter alone when we call to mind that there is a normal 
secretion in which sugar may be found under even normal cir- 
cumstances. The milk of carnivora contains it.* 

* Bensch has put on record the presence of sugar in the milk of bitches fed 
entirely on meat. " Annalen der Ch. und Pharm.," Bd. lxi, 221, quoted in Dr 
Lehmann's "Phys. Chemistry." 



486 DIABETES. •'* 

Moreover, sugar may be formed in the laboratory by a process 
of decomposition without the presence of life. Nay, rather only 
when life is extinct. The simple application of oxygen will cause 
some animal substances to be converted into sugar. This has 
been noticed by Dr. Claude Bernard to be especially the case 
with the tissues which form the liver, which, carefully washed 
from blood and exposed to the air, quickly become copiously sac- 
charine. So that your patient has a fertile source of sugar in his 
own body, even if none is supplied by the aliment consumed. 
He carries in his abdomen about three pounds of viscus capable 
of easy conversion into sugar. 

But remark it is dead liver, not live liver, which in health is 
decomposed as above stated. Normal vital action seems to have 
another way of removing the hepatic. substance, for during life 
no sugar can be detected as formed from the organ. Diabetes, 
then, like all diseases of which we know more than the superficial 
symptoms, turns out to be a death in life, an antepast of the 
post-mortal properties of the bodily constituents. This is an 
additional reason for casting about how best to apply restorative 
medicine in its treatment, and for urging an ample supply of 
the right material for revivifying the frame. If the dying liver 
is passing off quickly by the kidneys, we must give the patient 
quickly the wherewithal to make new liver. Now you gain an 
additional reason for enforcing animal diet in diabetes. 

To accustom this patient to leave off by degrees vegetable 
aliments, I gave him first captain's biscuits for a fortnight. 
During that time scarce any weight was gained, and the urine 
was but little altered. He liked those biscuits very well. Then 
I ordered him bran biscuits, but he said they were so nasty he 
could not eat them, and he wasted some of his milk in trying 
to make them palatable. Nevertheless he increased in weight 
by two pounds during two weeks, and made eleven pints less 
urine weekly than on his first admission. And this although 
he drank as much as he felt disposed to take. 

After this Mr. Van Abbott was good enough to give him a 
supply of the gluten bread, which is manufactured by his firm 
according to the prescription of Dr. Bouchardat. For a week 



DIABETES. 487 

he tried hard to eat it in addition to his former allowance of 
meat; but I am sorry to say he failed in acquiring a taste for 
it. His appetite fell off during the experiment, he lost half a 
pound of the weight he had gained, and was so annoyed at being 
pressed to eat the gluten bread that he insisted on returning 
home on July 12. 

My own feeling is that we do not act wisely in enforcing a 
dietary which is really unbearable by the patient in any chronic 
disease. The great object to be gained is to conciliate the stom- 
ach, appetite, and fancy into taking the greatest possible amount 
of animal food, and if practically you find that the patient eats 
more by having a biscuit, or a crust, or even vegetables with his 
meals, it is better to give him his way than to act the tyrant. 

As to drugs : 

Opium was given to this patient for a week. It did not in 
this particular instance seem to exercise any influence at all. 
However, in some cases it certainly does seem to diminish the 
excretion of water. But is that any advantage ? or is it an ad- 
herence to the prejudices instilled by antiquated theories that 
we reckon on help from such an interference ? I own it seems 
to me that if the blood gets loaded with sugar, as analysis proves 
to be the case, it is better that the sugar should be washed out 
by an ample diuresis, than that it should remain at the risk of 
poisoning the tissues. I have never distinctly traced any harm 
to opium, truly; but I have traced harm to a drug whose action 
is similar. Cinchona also like opium diminishes the flow of 
urine, and I once gave that to a diabetic patient. After a short 
time he became comatose, and after death I found a collection 
of fluid in the ventricles in the brain. The effused serum was 
loaded with sugar, which it was the business of diuresis to have 
diluted and washed away. 

For this reason I shun cinchona in diabetes, even when I wish 
to give tonics for the sake of increasing appetite. I prefer iron 
and strychnine. An elderly patient of mine with moderate di- 
abetes is now taking these drugs, with advantage to his strength 
and digestion, and without any hurtful action exhibited in the 
urine. 



488 DIABETES. * 

The iodide of potassium, which you see prescribed on the med- 
icine card, was given on purely empirical grounds. There are no 
drugs known to do good to the essential phenomena of diabetes; 
there were no secondary symptoms demanding special medica- 
tion ; so I thought it a fair case for an experiment. The result 
was that at all events no harm was done; the patient continued 
to gain weight and strength, and did not exhibit any of the usual 
symptoms of intoxication by iodine. 

This is not like substituting an experiment in search of a pos- 
sible specific in place of rational treatment ; such conduct is in- 
deed most blameworthy ; but here there is no medicine omitted, 
for there is none to be given that offers any hope of its possess- 
ing an alterative agency, and it is a question of either some- 
thing new or a mere placebo. I shall try the iodide again on 
the next similarly pure and uncomplicated case. 

People sometimes feel a doubt how far they ought to gratify 
the patient's unnatural thirst. On this point the same con- 
siderations weigh with me which influence my objection to cin- 
chona. I think there ought to be kept up a flow of water 
through the system in proportion to the abnormal quantity of 
sugar in the blood, in order that no retention or discharge in un- 
usual places of this material may take place. I therefore let 
patients drink as much as they feel disposed for. 

You will find that the demand for fluid food is closely pro- 
portioned to the quantity of sugar required to be got rid of. 
Thus when the dietary is changed from starchy to meat food, 
much less is drunk, and much less is evacuated by the kidneys, 
though no restriction is placed upon the thirst. Such was the 
case with the lad now lectured on ; during the second week he 
made twelve pints less urine, though he was recommended at 
the same time to drink as much water as he liked. The specific 
gravity also of the secretion was not raised, which it certainly 
would have been had the diminution in quantity depended on 
any other cause than a diminution of the instinctive call for 
diluents. I believe the thirst depends on the saccharine con- 
tents of the blood ; it is therefore wise to gratify it, and to pro- 
vide the normal outlet for the abnormal constituent. 



LECTURE XXXIX. 

MORTIFICATION. 

Complete death of a part, contrasted with necrobiosis — Case of 
mortified toes from cold and senile arteries — Treatment ex- 
plained — Preservation of dead tissue from decomposition — 
Defense of weak vessels — Food — Appetite — Action of oxygen 
on sore places — Carbonic acid the normal atmosphere of in- 
ternal parts — Superiority of nature s surgery to mans. 

{Clinical, St. Marys, June 27, 1862.) 

The greater part of my lectures have been taken up with 
those forms of partial interstitial death, those mixtures of half- 
life and half-death in the same substance, which constitute 
morbid actions. Schulz calls them " nekrobiotic processes.'' I 
wish now to call your attention to complete death, or "nekrosis." 
I do not mean complete death of the whole body, — I said the 
few words I had to say on that head in my introduction, — but 
complete death of a part, the general health remaining untouched. 

You had an excellent example on which to study this phenom- 
enon in an old man who has been in the wards for the first five 
months of this year with mortification of the foot. 

His history is as follows : 

G. B., aged sixty-six, is a cowman of steady religious habits 
(as I learn from a cousin of his whom I know speaks truth, for 
she taught me to do so — in fact my nurse), living very temper- 
ately on small wages, seldom eating meat, and still more seldom 
taking beer or any alcoholic drink. In appearance he is quite 
a model for Burns's cotter. His health has been as good as he 
deserves, though he has felt for the last twelve months or there- 
32 



490 MORTIFICATION* 

abouts not quite so young as he was, and you may observe a sure 
sign of age in the eye, an arcus senilis around the iris. In the 
second week of last December he got a severe chill by sitting 
for several hours in wet clothes. He had then much pain in the 
left foot, and he observed that it was swollen and that its nails 
were livid. This blueness and swelling passed off when he had 
lain up for a few days, and then he went to his work again. But 
at Christmas-tide again he got wet through, and back came the 
pain in the foot and ankle. On looking at it he found all the 
toes above and below and their balls quite black, the blackness 
reaching about half an inch beyond the balls in toward the 
hollow of the sole. Sensation here was quite lost, the whole 
foot and ankle were swollen, red, and very painful, the pain ex- 
tending up the inside of the leg. In this state he came into the 
hospital on January 3. His appetite then was quite gone, the 
tongue was smooth and clammy, with a brownish center, the 
pulse large and empty, with the sharp stroke usual in old age. 
Nothing abnormal could be detected by auscultation in heart or 
lungs. 

He was laid in bed with the foot raised above the level of the 
body. The leg was wrapped in cotton wool, and kept warm with 
a hot bottle. The swelling went down, and circulation returned 
to the ankle in a week. An offensive smell being perceived to 
ooze out from some weeping cracks between several toes, the 
foot was kept in charcoal powder. When after two months the 
gangrene began to separate at the edges, a fermenting yeast 
poultice was applied night and day. For three weeks he had 
u teacup diet," i.e. a teacup of beef-tea or milk every two hours, 
from lour to six ounces of port wine, and bark. He then re- 
covered appetite, and ate meat largely, going on with his wine. 
At the end of May he went out, having lost the last phalangeal 
bones and the cellular tissue from each toe, some from the sole 
of the foot, and his old nails. However, new though deformed 
nails are growing. 

The object of this treatment, as you may readily guess, was 
not to restore life to the completely mortified parts, but to the 
mortifying tissue in their neighborhood. Our province is not to 
raise the dead, but to heal the sick. 



MORTIFICATION. 491 

The only attention which I paid to the destroyed portions 
was to keep them from putrefying and to keep them attached 
as long as may be to their parent foot. You will perhaps say, 
" Why, Mezentius-like, bind the living to the dead in hateful 
union ? Why not rid the poor man of what he can never use 
again?" There are several objections to such a trenchant 
course of procedure. In the first place, probably your rough 
hand would root up the wheat with the tares, and could hardly 
help cutting away much tissue capable of regaining vitality. 
Secondly, the wound would still further render inefficient the 
degenerated blood-vessels which were the cause of the disease ; 
they would be unequal to the task of healing up the sore, and 
further mortification would be likely to ensue. Thirdly, there 
is no better guard for the dying tissue against external injury 
than the dead tissue which exactly fits on to the place, and shuts 
out the air more thoroughly than any plaster ever invented. 
There must, however, be this proviso, that it does not get putrid, 
so as to be a nuisance to its neighbors. 

With the view of securing this preservation from decay, we 
adopted precisely the principle on which meat is preserved for 
food — we kept the tissue from air, we kept it from moisture, and 
we salted it. The foot was carefully wrapped up, first in cotton 
wool, and then in charcoal powder. But moisture at last began 
to soak out from the inside, and the parts got podgy ; then I 
used salt and muriatic acid, which acid, uniting with the soda of 
the serous exudation, also formed brine, and assisted in harden- 
ing the tissue. 

So much for forming what I conceived to be the best mechan- 
ical protection to the weak, half-dying blood-vessels and nerves 
in the neighborhood of the dead. Half-dying as they were, 
we were asking of them extra work, even the growth of new 
connective tissue, new skin, and a scar, — in fact, all we could 
get out of them. Urgently needed therefore was this protec- 
tion. 

Let us do all we can to save them their ordinary work. With 
this view the foot was kept absolutely quiet, and raised above 
the level of the chest ; so that at all events it might be spared 



492 MORTIFICATION.' 

the exertion of the usual elastic force in the vessels to resist the 
gravitating blood ; at the same time the defective animal heat 
was reinforced by a vessel of warm water always kept in close 
neighborhood. 

And let us lay in good store of the materials for new tissue. 
Food was administered every two hours in small quantities and 
in a liquid form, for his stomach turned at the notion of eating. 
Bark was prescribed, and a daily dose of wine. The desire was 
begotten by the gratification of it, and gradually the appetite 
rose ; so that not only did he relish " ordinary diet," but before 
a month was over asked for an extra allowance, in spite of being 
unused to meat, and in spite of having no exercise or any of the 
usual calls for nutrition in muscular exertion. Remark here that 
you must not wait till a siek body of its own accord asks for 
nourishment by instinctive hunger. In health the stomach is 
" clock to itself," but in sickness the instinct, or corporeal rea- 
son, is overclouded, and the spiritual reason must be its clock. 
As life returns, so returns the vital desire, and thankfully con- 
fesses the justice of the martial law established by its conqueror. 
As the new tissue grew it refused to be allied with the now 
foreign substance overlying it; the former kinship was dis- 
owned ; it was no longer bone of its bone, and flesh of its flesh ; 
and so there was a separation at the edges of the black mass, 
and some of the new birth was laid bare. An abnormal and 
hurtful state of things is thus introduced ; it is most unnatural 
and painful for tissue to have to grow while open to the sharp 
influences of oxygen — the "biting bitter air," as poets call it. 
Where oxygen is intended to touch a living surface, that surface 
is closely clothed in skin or mucous membrane. A fluid loaded 
with carbonic acid is the healthy atmosphere of an inside part, 
and thick darkness its light. So we restored as far as we could 
the conditions of growth and healing ; we covered up the part 
with a fermenting poultice of yeast, which was continuously 
giving out warmth, moisture, and carbonic acid. Under its in- 
fluence the restoration went on prosperously. 

I believe an atmosphere like this of carbonic acid would be 
exceedingly useful in all cases of wounds, and that it is from its 



MORTIFICATION. 493 

production that internal lesions, as a rule, heal so much quicker 
than external. The instinctive surgery of the dog leads him to 
cover his wounds with saliva and warm breath, and I do not 
think man can do wrong in learning of his dog's instructress, 
experience. In the brute the experience is hereditary, in the 
man it is almost entirely individual. In the brute it is purely 
selfish, in the man it is philanthropic. But as a physician, I 
have no opportunity of putting the principle into practice. 

In the fourth month the soft parts, the connective tissue and 
muscles gradually rotted off, like the flesh of the corpses watched 
by the concubine of Saul and by M. Devergie.* And then you 
were able to appreciate the full advantage gained by the con- 
servative practice. Had a knife been used, nobody would have 
removed less than the terminal phalanges of the toes at the very 
least ; for they all looked black and dead. But what do you see 
here ? The pads of the toes have rotted off, the bones have dried 
up into brittle, brown sticks, which are being gradually sepa- 
rated. But on three of them the nails are growing ! — distorted 
indeed, and not ornamental, but still true nails. A rough and 
ready operator would never have thought of leaving the little 
bits of nail-matrix, which have themselves grown, and also given 
birth to those defenses so essential to comfort. 

I have occupied the greater part of a clinical lecture with this 
man's semi-surgical case perhaps to the surprise of some, who 
will cry "ne sutor ultra crepidam." I am desirous, however, of 
thus pointing out to you that I place no limit to the application 
of restorative principles. In surgery as much as in medicine 
the thing mainly to be considered and treated is the living part, 
not the dead part — the normal functions, not the abnormal— the 
health, not the disease. Mark what is wanting, and what is left 
whole ; supply the former, and use the latter. Make your chief 
end of ends, " the renewal of life."f 

It will require some courage in you consistently to follow this 
advice. You may be accused of dishonesty for not doing more ; 

* See illustration at the beginning of Lecture I. ^ 

f This was the half-title of the first and second editions of my clinical lec- 
tures. My reason for altering it is given in the preface to this volume. 



494 MORTIFICATION. * 

and I have even heard it denounced as quackery to call that end 
which is consequent on our fostering care of the powers of life 
"a cure." Were this true modesty, the " non hsec humanis 
opibus" of an Iaspis or the " altitudo" of a David, one would 
shrink from blaming it ; but it is not so ; a sort of contrast is at- 
tempted by assigning the word " recovery" to such a result, and 
" cure" to that which may follow antipathic treatment ; and it is 
implied that no credit is due to the medical attendant for the 
former, whereas by the latter he has fairly earned his reward. 
In point of fact there is no contrast at all ; every restoration to 
health must depend on a renewal of the deficient life ; in every 
case this renewal must be wrought out through the agency of the 
vitality remaining yet uninjured ;* and all counsel given by us 
which contributes to bring about this result is strictly curative. 
Fear not the charge of having done too little ; refer to success 
as an evidence of real activity. 

* See Lecture II. 



LECTURE XL. 

IMPORTANCE OF THE DIGESTIVE ORGANS 
IN THERAPEUTICS. 

Disease of the digestive viscera affects the whole tody — Instances, 
tuberculosis, degeneration, mental disease, gout and rheu- 
matism — Digestive viscera the chief recipients of remedies, 
and not only of constructive, but of destructive and arrestive 
remedies — Effects in disease of healthy and unhealthy di- 
gestion — Importance of replacing destructive by the aid of 
constructive action — Digestive tract single. 

(St. Marys, April, 1862.) 

I am anxious that you should be duly impressed with the im- 
portance of the digestive viscera to the cure of disease. In 
every case, surgical or medical, the modification of the result 
produced by our efforts depends almost entirely on how far, how 
wisely or how foolishly, these organs are watched over; whether 
they are well or ill-treated, either by the scientific guidance of 
the skilled physiologist, or by the empirical rules of the routine 
practitioner, or according to the tradition of the nurse, or the 
instinct of the patient. Each and all of these may be useful 
guides ; but where there is a difference of opinion, I prefer 
trusting to the first-named principle of action, and so does the 
public, except when in a fit of obstinacy or prejudice, and so, I 
hope, -will you. 

It will be my endeavor, then, to give to the attention which I 
trust will be bestowed upon the functions of these organs, the 
rock-laid foundation of prescient science, and not the sandy sup- 
port of mere empiricism. 



496 IMPORTANCE OF DIGESTIVE ORGANS. 

To an unhealthy state of the digestive viscera physiology 
enables us to trace, by steps more or less distinct, several morbid 
conditions not manifested in the organs themselves, but affecting 
the whole body. Take for example the very common condition, 
tuberculosis. One cannot fail to connect both empirically and 
rationally this state with deficient supply. Among whom is it 
most frequent ? Among those who have either not enough to 
eat, or those who from imperfect assimilation are unable to con- 
vert into blood what they swallow. The starved fluid does not 
sufficiently stimulate the vitality of the body, connective tissue is 
removed by metamorphosis, and its place is supplied, not by new 
healthy connective tissue, but by a cheesy semi-vitalized sub- 
stance, which we call "tubercle." 

The next most frequent material cause of disease in the ana- 
tomical structure of the body is degeneration. By birth it is 
closely related to tuberculosis. Unrenewed effete particles re- 
main as fat in the tissues ; and so you get softened and dilated 
hearts, fatty liver, Bright's kidney, atrophic softening of the 
brain, apoplexy, &c. 

To the same cause may be traced an obscure inefficiency of 
mind, very common among our chronic invalids and habitual 
patients. They complain that they awake in the morning, not 
only unrefreshed by sleep, but seemingly more tired than when 
they went to bed. There is an unaccountable despondency and 
carelessness about the future, accompanied by a conviction that 
something or another unfortunate is going to happen. They 
have no power to prevent this ; and they are not sure they would 
exert the power if they had it. Their unwilling limbs are dragged 
languidly to the daily task, but they are quite unable to do any- 
thing as they ought. The figures get confused as the merchant 
adds up his ledger ; the clerk knows he has some important duty 
to perform, but cannot call to mind what it is ; to the matron 
even the light labors of daily housekeeping are a heavy burden. 
A morbid dislike to the idea of food causes the family meal to 
be simply repulsive. Sleep is sought, and perhaps obtained, but 
is broken by painful dreams, or fidgets, or wakefulness. If there 
is an inborn or hereditary tendency to insanity, now is the time 



IMPORTANCE OF DIGESTIVE ORGANS. 497 

when it bears fruit ; spectral illusions, derisive, tempting, or 
foolish voices half deceive, half irritate the victim ; and he is for- 
tunate if he is saved from crime or a mad-house by the curable 
source of his unhappy state being correctly traced. But if there 
is no previous tendency, the mental miseries may go on for years, 
and yet not produce any positive unsoundness of mind. In 
these cases, without further symptoms than those named, you 
may be safe in referring the origo mali to the digestive canal ; 
and the success of your treatment will usually confirm your 
diagnosis. 

There is also a suspicion that some acute diseases of the fibrous 
tissues, such as gout and rheumatism, may be due to imperfec- 
tions of the digestive organs. During these ailments organic 
acids, uric or lactic, and perhaps others, yet unnamed, are found 
in excess over the alkalies ; or rather more correctly speaking, 
the alkalies are in a state of deficiency in respect of the quantity 
of acid ; and, as acids are certainly formed by the decomposition 
of the food, and one of them (the lactic) especially in great abun- 
dance, while the alkalies also come from the food, it is presumed 
that the cause of the malady resides in the viscera which contains 
the food during digestion. This idea that the digestive organs 
are to blame for gout and rheumatism is of very old date ; yet it 
must be confessed that the evidence for it does not increase; and 
it remains, as of yore, a strong presumption, waiting to be con- 
firmed by a physiological tracing of its steps. 

Whatever value we may attach to the evidence of the depend- 
ence of diseases on the digestive organs, it is very clear that we 
look to them for relief from those diseases. Out of the six or 
seven hundred forms of drugs in habitual use, very few indeed 
are not occasionally offered to the stomach for acceptance, and 
an overwhelming majority of them are adapted for use only in 
this way. If we are still to employ this time-honored agency in 
our attempts to cure bodily ailments (and I see no threatening 
of a change at present), it is surely a matter of great interest to 
secure the active working condition of the stomach. It is waste 
toil to try and enter locked doors. 

A great advantage of paying special attention to the digestive 



498 IMPORTANCE OF DIGESTIVE ORGANS. 

organs is that, as a rule, they are more directly curable, and that 
by their means distant parts, otherwise out of our control, may 
be favorably influenced. The evil of neglecting them is obstinate 
disobedience of the disease, or rather of the body of the patient, 
to any drug administered ; recovery rather in spite than by rea- 
son of it ; and in a candid mind the development of skepticism, 
the great enemy of right reasoning in medical matters. 

Let it be observed that it is not constructive medicines only, 
not alone aids to the normal work of the alimentary canal, that 
we try to put in through its walls. We look to it also to take 
up those whose agency is, physiologically speaking, the direct 
converse, whose effect is that of augmenting destructive meta- 
morphosis. We call upon the bowels to absorb calomel as well 
as bark and wine and oil. We shall find it then of equal im- 
portance to have them in a normal state when our aim is de- 
struction, as when it is construction or arrest. 

When a sudden poison or paralysis has fallen on these gates 
of entrance, our hands are paralyzed too ; the staffs we lean on 
fail us. What buckets of physic used to be poured through the 
half-dead bowels in our first epidemics of cholera ! It might 
just as well have been thrown at once into the night pan — its 
ultimate destination if the patients lived long enough.* 

So that calomel pills, and calomel powders, and opium, and 
Cayenne pepper were a frequent constituent of cholera stools ; 
in short, I believe that nine-tenths of the drugs swallowed in the 
stage of collapse followed the same fate, or the patients could 
not have survived the poisonous doses which are recorded to 
have been given. 

But it is when reconstruction is the immediate object of the 
remedies sought to be administered, that the importance of the 
digestive organs is most obvious. Mark the difference between 
two consumptive patients taking cod-liver oil. One, whose di- 
gestion has been carefully brought into a healthy state, swallows 
it in large quantities, at any time of day you please, complains 

* I once found a draohm of ipecacuanha, which had been administered with 
other emetics three hours before death, safe in the cardia of a patient, in whom 
it had produced no vomiting, and had not been moved toward the pylorus. 



IMPORTANCE OF DIGESTIVE ORGANS. 499 

of no inconvenience, enjoys life, does credit to the doctor, laughs 
and grows fat. Another, in consequence very likely of some 
easily removable cause, nauseates the smallest dose ; if in spite 
of instinctive repugnance it be forced down, it gets rancid ; fetid 
eructations follow; and the patient not only gets no advantage 
from the drug, but is prevented by it from deriving the usual 
benefit from the daily meals ; appetite is lost, and rapid emaci- 
ation shows how little construction is carried on in the tissues. 

Watch a case of typh-fever, and see what immediate improve- 
ment follows the shedding of the dead epithelium with which the 
mucous membranes have been coated — a change which is an- 
nounced by what is called the "cleaning of the tongue/' but 
which foreshadows much more, in fact the cleaning of the whole 
intestinal tract. See how immediately on this the poisoned nerv- 
ous system begins again to renew its life, and delirium ceases, 
as new nervous matter fit for duty is generated. Or watch 
another less fortunate case of the same malady, how as the 
tongue gets dirtier and dirtier and drier and browner each day, 
the weakness of the nervous and muscular system increases, and 
hope is more and more clouded over. 

In both instances, the difference between one case and another, 
between the patient who is a credit and a joy to us and the pa- 
tient who continues to wring our heart with anxiety, lies in the 
more or less vitality of the digestive mucous tract. 

Then again, however skeptical we may own ourselves as to the 
dependence of gout and rheumatism upon the digestive viscera, 
it is through those organs that we mostly try to reach the 
malady. 'Tis through those organs that we endeavor to get our 
large doses of potash and our iodide of potassium into the blood. 
There are practitioners who, in their treatment of these affec- 
tions, rest more exclusively on the drugs named than you have 
seen me do ; and to them even still more than to us must the 
integrity of the digestion be a care. 

We must remember also that it is of no use to employ the 
best possible means of staying the morbid symptoms, unless the 
digestive organs assimilate sufficient material to replace that 
which is diseased, and to remove which we are bestowing our 



500 IMPORTANCE OF DIGESTIVE ORGANS. 

pains. Labor is wasted in clearing away abnormal structure, if 
new structure does not take its place. To that end the only 
path is to insure the assimilation of food. And to insure the 
assimilation of food, the stomach must be in working order. So 
that in point of fact the only fair trials of depletory measures 
must be connected with feeding, and they who would uphold 
their good fame must be careful of their patient's digestion. 

The digestive tract has not the advantage enjoyed by the 
respiratory and by the upper part of the urinary apparatus, and 
other parts, of being double. An animal has two lungs, two 
kidneys, two hemispheres to his brain, two testicles or ovaries, 
but only one stomach, and one intestinal canal. This is a fur- 
ther reason for great caution in preserving each in its integrity : 
we have less to spare for disease to affect. A deposit of tubercle 
(for instance) the size of a nut in the pulmonary tissue may be 
neither here nor there, may be never known by its effects; but 
put it in the heart, in the peritoneum, or in Peyer's glands, and 
what a disturbance is produced ! 

This singleness also helps to explain the powerful influence 
which derangement of any one of its parts has not only over the 
whole tract, but over the whole body and mind. No chain is 
stronger than its weakest link, and an interruption of the func- 
tion at one point is an interruption of the whole. 

[I. do not therefore think it will be out of place in a volume 
of lectures selected and edited as illustrations of restorative 
medicine or the artificial renewal of life, to insert several given 
a few years ago, which were specially devoted to a consideration 
of disorders of the stomach and bowels. I look upon these 
viscera as a means of cure, as an agency for me to employ for 
the renewal of life, in fact as part of my Materia Medica. 
The lectures which follow may then be considered as being 
upon the subject of therapeutical agents rather than as on the 
subject of disease, and are set together as having that natural 
bond of union. 

Questions of morbid anatomy and diagnosis are here, as 
throughout the volume, noticed as shortly as possible, and pa- 
thology introduced only so far as may be needed to afford a 
reason for treatment.] 



LECTURE XLI. 

INDIGESTION IN GENERAL. 

Justification of the term as designating a class of diseases — 
Position of it in nosology — Its importance — Examples — Its 
action on chronic disease, on acute diseases — Use and abuse 
of purgatives — Cause of death in acute fevers — Mode of 
introducing food. 

{Extra Course, St. Mary's, Summer Session, 1857.) 

The term "indigestion" or " deranged digestion" speaks to 
the mind of the physician of a very large class of morbid phe- 
nomena, various in their nature and appearing under a great 
variety of circumstances. There are those who would banish 
the words from our nomenclature; some because the outward 
manifestations are so diverse that it is impossible to bind them 
together in any symptomatic nosology; some because the parts 
of the body whose morbid states induce indigestion are so many 
that it cannot be brought under any anatomical arrangement. It 
is quite true that a definition of it cannot be given according to 
the symptoms, and equally true that it cannot be called a disease 
of one part or of any set of parts or tissues. When symptomatic 
phenomena are made the principle of classification, those at- 
tendant on this morbid state are so numerous and so discordant 
that they appear in every class ; and if the organs that originate 
diseases are employed to give them names also, there are very 
few organs in the body which do not sometimes produce the dis- 
order in question. Still to the practitioner and to the common 
sense of the non-medical public the name has a distinct meaning, 
and is a definite guide to action. No nosological, anatomical, 



502 INDIGESTION IN GENERAL. 

or even chemical considerations have prevailed over it, simply 
because it indicates a true thing, because it applies to a class of 
disease having a connecting link in nature, though not in some 
of our artificial systems. 

The common link which ranges into one class the diseases of 
deranged digestion is a partial defect in the necessary supply of 
that of which the body is built up, before it arrives at the medium 
of distribution ; these diseases are anterior to assimilation and to 
the blood; they intervene between life and the new matter which 
it seeks to renew itself withal. 

This explains the fact mentioned before and familiar to us all, 
of deranged digestion affecting more or less all the functions of 
the body, and producing such a variety of morbid phenomena as 
immediate or remote consequences. It perverts incipient life at 
its very source, and therefore perverts all its future manifesta- 
tions. 

I am very anxious that you should have brightly pictured on 
your minds this idea of the position in pathology of diseases of 
digestion. It is of the utmost importance in your treatment of 
patients. It is of no use for you to pour in remedies, however 
suitable for the removal of some morbid constituents of the body, 
if the new material which is to replace it is itself insufficient in 
quantity or morbid in quality. While if you set to Avork in 
another way, and endeavor to provide healthy material, this of 
itself will act as a remedy, even though other treatment should 
have been neglected. Make it a universal rule, then, that the 
special medication is never to interfere with or take the place of 
the supply of the materials of life. 

In the management of a deranged digestion, whether existing 
alone, or as a complication of other complaints, it is certainly 
important to know what organs are in any of the degenerated 
conditions which form the province of the morbid anatomist. 
Your prognosis is modified, and to some extent. your treatment 
is affected by such knowledge. I do not deny the importance of 
this, but I assert that it is infinitely more important to observe 
the functional disturbances which are the immediate impediments 
to the healthy renewal of the body, and to learn how to modify 



INDIGESTION IN GENERAL. 503 

them for the advantage of the patient. You may remember my 
pointing out in the hospital the other day, with respect to a con- 
sumptive man, how little it helped us to know that half of the 
upper lobe of each lung was filled with crude tubercles: pulmo- 
nary remedies had been of no benefit to him; but the reflection 
that the stomach was secreting an excess of mucus at the same 
time with the lungs, led to effectual means for the relief of the 
poor man's progressive emaciation, cough, and other distresses. 
I also, a few weeks ago, called your attention to a girl, the mitral 
orifice of whose heart was narrowed by rheumatic inflammation 
in childhood. On her being carried into the hospital, her face 
was like that of a corpse, and she could not stand without faint- 
ing from palpitation. I presume no sane student would expect 
to see remedies applied for the dilatation of that mitral orifice 
whose contraction is the source of evil : despair was not an 
illogical conclusion from the diagnosis, and I was but little sur- 
prised to hear the remark ; "This is not much of a case for 
treatment." Yet observation of the functional state of the ali- 
mentary canal, indicated by the oedematous tongue and fauces, 
made me express an expectation that she would walk home with 
color in her cheeks. This she has been able to do, and the 
better-nourished heart now beats steadily and evenly; though 
its mitral orifice is as small as ever, if the ear and stethoscope 
are to be trusted. 

On stating in consultation an opinion that some viscus is 
chronically degenerated, one is often met by the remark, "Well, 
what is to be done? we cannot cure that." Very likely not; 
then try and find something else which you can cure. In the 
great majority of your patients you may find this curable some- 
thing in functional impediments to the entrance of nutriment 
into the medium of assimilation; and when you once can get nu- 
triment in, it will act as the best medicine. Do not, therefore, 
give way to despair, even after it has become certain that the 
principal viscus which gives a name and origin to the disease is 
incurable; and repress any conscientious fancies that you are 
not fairly earning your fees in giving careful attention and 
advice, though you prescribe little for the organ mainly affected. 



504 INDIGESTION IN GENERAL. 

It is never too late to try and administer to the failing organ the 
most potent of all medicines, the healthy human blood of the 
patient himself. 

The more I see of disease the more convinced I become that 
the most important function for us to pay attention to in all 
cases is the digestion ; in chronic cases it outweighs all the other 
functions put together. I am led to this conclusion not so much 
by physiological reasonings, or by the important position of this 
function in the great circle of life, as by observation of the effects 
of remedies, prescribed perhaps with quite different views, and 
often without any thought of the digestion at all. The effect of 
climate, for instance, in pulmonary consumption is proportioned 
with extreme accuracy to the degree in which the absorption of 
food is improved or injured by it. I had a striking instance of 
this a few months ago, in the comparison of letters which I re- 
ceived at the same time, about a couple of young ladies whom I 
had sent to pass the winter in a warmer climate. The elder 
(S. S.) was last year much the more advanced in disease; half 
of the right lung was rendered impervious to air and immovable 
by tubercle, local inflammations, haemorrhages, and pleural ad- 
hesions. She had hlso frequent dysmenorrhoea, and occasional 
menorrhagia. The younger (E. W.) had a small deposit of tu- 
bercle at the apex of the right lung, which excited cough, but 
no haemoptysis or pleurisy. She was the stronger and more 
muscular of the two, and had least right to hereditary disposi- 
tion, for all her family are alive, while S. S. has lost her mother 
by phthisis. Both had been under long courses of medicine by 
my direction, so I set them to begin the winter at any rate, and 
to go on as long as circumstances admitted, without any. What 
now is the result which I said struck me so forcibly? S. S., the 
most diseased anatomically speaking, who had certainly the 
greatest amount of morbid tissue in her body, found the warm 
air assist her sluggish circulation, enable her to take exercise, 
improve the appetite, and add unwonted energy and spirits. No 
food was passed undigested, and the evacuation from the bowels 
was normal in time and quantity. The consequence of which 
condition of the assimilating organs, bowels, and blood, has been 



INDIGESTION IN GENERAL. 505 

a most decided amelioration of the pulmonary local symptoms, 
in spite of an intervening attack of haemoptysis. There is scarce 
any pain, cough, or dyspnoea; she has increased in strength and 
weight, and boasts in her letter that she had one day ridden her 
pony five-and-twenty miles. E. W. had a tendency to a relaxed 
condition of bowels — not absolute diarrhoea, but the passage once 
or twice a day of unformed pultaceous stools, containing a large 
quantity of undigested food. It was easy enough by medicines 
to prevent the motions being too frequent, but difficult to amend 
the assimilation of aliment. This diathesis seemed aggravated 
rather than improved in the mild climate; there was greater and 
greater inability to take exercise; then a return of pain and ten- 
derness in the upper ribs, and at Christmas time the surgeon in 
attendance found a deposit of tubercle taking place at the apex 
of the left lung, in addition to what already existed in the right. 
Emaciation then commenced, and continuously progressed, quite 
unchecked by eod-liver oil and other expedients, which I thought 
it right should be tried, though without much expectation of 
success. In this patient m}^ only hope is in the restoration of 
the digestive organs to a healthy state. 

The remedy, the effect of which I thought was strikingly ex- 
emplified in this pair of cases accidentally reported together, 
is soft and warm air in incipient consumption. The agreeable 
effects on the respiration, the relief of dyspnoea, the power of 
getting out into the open air were equal in both, — but how dif- 
ferent has the result been ! 

A very moderate experience of the cases we have seen together 
in the hospital will soon enable you to class a dozen or more as 
resembling in their type one or other of the two above quoted. 
The atmosphere of our well-ventilated wards, and their even 
temperature, in comparison with the depressing coldness and 
chilly damps of the streets whence our patients come, repre- 
sents on a small scale what Torquay, Madeira, and Mentone are 
to the wealthy. And you may thus as students see, what private 
practice will still more strongly impress upon you, that the effect 
of climate on digestion is the most important part of its action. 
The atmospheric change alone without medicine will benefit those 
33 



506 INDIGESTION IN GENERAL. 

who resemble the class represented by S. S., more or less, in 
proportion to the extent of their disease, while those portrayed 
by E. W. will usually grow worse in spite of drugs. 

In all forms of dropsy, again, the effect which you desire to 
produce by remedies is strikingly dependent on the condition of 
the alimentary canal. Where the portal system is congested, I 
have given that strongest of drugs, elaterium, in doses gradually 
augmented up to three grains, without any of the vigorous hy- 
dragogue action naturally following; and then, by applying a 
few leeches to the anus, so as to disgorge the abdominal veins, 
half a grain has produced excessive purgation, with reduction of 
the dropsy. 

Another striking example of the dependence of remedies on 
their influence over the digestion is found in anaemia. If, as 
generally happens, iron improves the condition of the alimentary 
canal, so that the stools, from being scanty, scybalous, and 
mucous, consisting mainly of wind and half-digested food, be- 
come natural and regular, then the body is renewed by fresh 
nutriment, and the strength is rapidly reinstated ; but if it irri- 
tates the mucous membrane, so as to make the evacuation irregu- 
lar, black, and slimy, your patient remains as anaemic as ever. 
Hence the importance of suiting to the case the different form 
in which the metal is presented. If ready solubility and pres- 
entation to the absorbing surface, in such a shape as to get an 
entrance of a large quantity quickly into the system, were the 
only thing to be considered, the question as to which is the best 
preparation might be left to the druggist. But it is not so ; very 
often the easily soluble salts so disturb the gastric mucous mem- 
brane that it refuses to pour out that secretion which is the chief 
solvent of albumen ; the food passes unaltered into the intestines, 
and putrefying there, increases the disease. Whereas a sparingly 
soluble form of the medicament passes unaltered through the 
stomach, and exerts its main energy on the intestines. Again, 
some preparations, both soluble and insoluble, are more or less 
astringent, and have various qualities acting on various parts of 
the alimentary canal, which render them appropriate or not to 
individual cases. So that not the most elegant, not the most 



INDIGESTION IN GENERAL. 507 

praised as ingenious by the druggist or scientific chemist, is the 
oftenest selected by the judicious physician, to whom the cure of 
the patient, not the harmony of the prescription, is the object in 
view. 

It ought to be better understood that the fitness of any sub- 
stance ingested, whether food or medicine, for its final destina- 
tion, is not the only thing to be considered. Its capacity for 
entering into the circulation must be taken into account, and, 
above all, its dynamic influence over the organs of absorption 
and digestion. As a general rule, iron is the chief agent we 
think of in anaemia. We think of it for its direct power of in- 
creasing the hsematin of the blood. Yet it is by no means always 
the first, or even the best remedy when the blood-disks are de- 
ficient from faulty assimilation. I remember when I was a student 
noting down as a paradox that salts and senna acted as a tonic 
in three cases running, where iron and bark and bitters had done 
no good ; yet that I could not find in any work a tonic action 
assigned to purgatives. I then saw that the action of medicines 
was not entirely according to their rating on our books. 

The fact is, that until you have removed the sluggish state of 
the regions presided over by the portal circulation, which are 
doing nothing but forming mucus and obstructing absorption, 
you cannot get the protein compounds taken up, and they form 
a much more important constituent of blood-globules than even 
iron. 

And it is not only the general health that is benefited by 
attending to the functions of the stomach, but even organs as 
far as possible removed from it in a physiological point of view. 
A patient consults me from time to time who has an enlarged 
prostate. When digesting well, his urine is quite transparent, 
and free from mucus, even when microscopically examined ; but 
if the stomach is disturbed by any imprudence or accidental ill- 
ness, there is a copious formation of pus in the bladder. 

I shall return to this subject when I come to speak of medi- 
cines separately; now I mention it merely as an accessible 
instance to show you how all-important in treating chronic dis- 
ease is the condition of the alimentary canal. 



508 INDIGESTION IN GENERAL. 

In acute disease you -will be almost equally disappointed with 
the effect of your remedies, if you do not, either by their means, 
or by other means in addition to their administration, bring the 
alimentary canal into a proper state for their reception. In no 
cases is this more marked than in erysipelas and delirium tremens, 
and you may have observed that I scarcely ever pass a bed in 
the wards containing a patient affected with one of these diseases 
without calling your attention to the fact. I point out to you 
that cinchona and wine are the proper remedies for the weak 
rapid pulse, the yellow pasty tongue, and the low inflammation 
of the skin in erysipelas ; but that if you give these remedies 
without clearing away the saburral epithelium from the stomach 
and bowels, they are quite thrown away ; the circulation con- 
tinues as weak as ever, and the patient goes on advancing toward 
death. But if you have got a purgative to act, and are then in 
time with your alcohol and bark, the corner is turned, and every 
change which takes place is a change toward health. I have 
often shown you, in the little room where we put raving cases of 
delirium tremens, a man who has been taking large amounts of 
laudanum, morphia, and solid opium, yet is as rabid and demon- 
haunted as ever, his eyes never closing to the horrible visions 
that surround him. But on giving him an efficient dose of salts 
and senna by mouth or rectum, powerful opiates become no 
longer requisite ; he goes off into a quiet sleep, sometimes with- 
out any more, sometimes with an ordinary quantity of laudanum, 
and the next day be is usually calm enough to be removed to the 
common wards. 

Do not misunderstand, or suppose me to have turned "evacua- 
tor," recommending an artificial diarrhoea as a panacea; on the 
contrary, I am anxious to warn you that there are cases where 
a purged state of the alimentary canal, natural or artificial, is 
most injurious. I would instance especially pneumonia and low 
fever. In the first, the treatment pursued is beneficial just in 
proportion as the bowels are not purged; and if you give a 
cathartic, you very often destroy all the good effect of your 
remedies. In adynamic fevers, the prognosis may be almost 
entirely governed by the average proportion of solid matter to 



INDIGESTION IN GENERAL. 509 

the liquid in the stools, and by the degree in which the food is 
digested. Any expedients which increase the amount of solid 
and diminish the liquid intestinal evacuations, any which promote 
the taking up of nutriment by the mucous membrane, are doing 
good ; any that act in a contrary way, do harm. 

In pneumonia and low fevers, three-quarters of those who die, 
die of starvation. I mean that the real immediate cause of their 
death is the non-renewal of the blood by the supply of fresh 
matter. Both veins and arteries are filled with a dark half-dead 
fluid, a great portion of which is incapable of fulfilling the func- 
tions of life at all. Expose this black blood to the air, and it 
remains nearly as black as ever. No oxygen will redden it, for 
it is too dead to imbibe oxygen, and it is only fit to be evacuated. 
But then, when it is evacuated, something must supply its place; 
new blood-disks capable of living and absorbing oxygen must be 
made, or the patient dies. If you think only of getting rid of 
this dead matter by blood-letting and other evacuants, or if you 
think only of arresting the rapid destruction of the still living 
matter by alcohol, you are taking an imperfect view of your 
business, and not doing all that may be done to renew the patient's 
life. At the same time that you fulfill the other indications, it 
is your duty to adopt expedients for promoting the supply of 
nutriment to the absorbents. 

That is not to be accomplished by throwing in at once a large 
quantity of food, which decomposes and stops digestion entirely. 
The alimentary canal either rejects the load or suffers from such 
treatment, and is all the more starved by the very abundance, 
like the Roman girl in Livy's legend, who was crushed to death 
by the stipulated rewards of her treachery. 

The way to attain your object is to give very small quantities 
of food at a time and very frequently, so that a continuous flow 
may be kept up through the alimentary canal without over- 
burdening it. The system of a patient laid up with acute disease 
is like that of a new-born infant, in the weak hold it has of life, 
and in the constant support it requires ; and the stomachs of the 
two resemble one another in the insufficiency of the meal they 
can take at once to satisfy their wants for any length of time. 



510 INDIGESTION IN GENERAL. 

Treat them, therefore, in the same way ; and as in proportion to 
its youth you order an infant to be fed frequently, so in propor- 
tion to their illness feed frequently your sick patients. A person 
prostrated by a fever or by inflammation of an important vital 
organ, such as the lungs for example, ought not to be more than 
two hours without food while awake, and I have not unfrequently 
administered it in doses of a few spoonfuls every hour, night and 
day, with decided advantage. 

You may take a lesson, too, from the nursing of infants as 
respects the nature of the food ; milk is the most perfect you can 
give. The only disadvantage is, that the caseine may be sud- 
denly coagulated all at once in the stomach, and then, instead 
of passing on gradually, it has to remain there till enough gas- 
tric juice is secreted to dissolve it, and enough energy exist in 
the peristaltic muscles to move the mass onward ; till which time 
it stops the way. The better plan is to mix sufficient lime-water 
with the milk, to prevent any large quantity of lactic acid from * 
being free ; much of the milk will then pass the pylorus uncoagu- 
lated, or at any rate in very small coagula, and be digested by 
the intestinal juice, with no labor to the stomach.* 

You saw a month ago, in the Victoria Ward, a striking in- 
stance of the effect of mere nutriment so administered as to be 
capable of being absorbed in acute disease. A young woman, 
the subject of pulmonary tubercle, became affected with pneu- 
monia of the whole of one lung. Her lips were livid ; the pulse 
not to be counted ; the respirations irregular, and between forty 
and sixty in the minute ; there were rales from the collecting of 
mucus even in the bronchial tubes of the unaffected lung ; the 
tongue had a smooth yellow coat ; and the repugnance to food 
was very great. She had up to this period had nourishment 
given, or rather offered, only at the usual times of meals. She 
had had some stimulants, but they had been thrown up. I then 
ordered her a pint and a half of beef-tea and two pints and a 
half of milk, guarded with a pint of lime-water, to be taken, a 

* On the action of the intestinal juice see Bidder und Schmidt; "Die Ver- 
dauungssafte (von Darmsaft) ;" and "Digestion and its Derangements," by the 
author: Book I, chap, v, sect. 4 and 5. 



INDIGESTION IN GENERAL. 511 

small portion at a time every hour, so as to finish the whole in 
twenty-four hours. The next clay a sudden revival had taken 
place ; the tongue had cleaned ; the respirations were about 
twenty-five or thirty ; and so she continued to hold on to life 
for five clays, when a relapse occurred, and she died. She died 
truly, but it seemed pretty clear that death would have occurred 
from the first condition in which the patient was seen by you, 
except from the continuous supply of nutriment. I cite this case 
rather than any of those where final recovery takes place, be- 
cause in them you might doubt whether the disease really is of 
a necessarily fatal nature ; whereas here you have proof of the 
fact in its killing the patient soon afterward. It was of a fatal 
nature, yet death was arrested for a time, and the sharpness of 
the symptoms made the changes more striking than in patients 
where your memory has to cast back for days or even weeks, in 
order to trace the effect of treatment. 

Another patient, now convalescent, illustrates a still more 
purely dietetic treatment of acute disease. I mean a young 
man who was brought in three weeks ago with low fever, his 
tongue dry and brown, rose spots on the skin, weak fluttering 
pulse, and the stools smelling like rotten flesh. The only drug 
I ordered him was a small quantity of chalk-and-mercury powder 
at night, and some effervescing saline draughts.* You have 
often seen under such treatment the fetor of the stools continue, 
and great weakness follow, even in those fever cases that ulti- 
mately get well. But I ordered at the same time a diet of milk 
and beef-tea, to be taken in small quantities every hour, and a 
few ounces of port wine. To assist the absorption of this nutri- 
ment I gave him also a scruple daily, divided into three doses, 
of a powder containing pepsine ; and I was curious to know what 
the effect would be on the digestion, for it was the first time I 
had given it in low fever. The result was most encouraging — 
for the stools immediately lost their putrid fetor, and the food, 
instead of being passed in a putrid undigested state, seemed to 
be entirely consumed in the bowels. In spite of several dis- 

* I had not at that date commenced the acid treatment of continued fever 
detailed in a previous lecture. 



512 INDIGESTION IN GENERAL. 

couraging symptoms, I have never seen a case of bad fever where 
the stools were less fetid, or where there has been less emacia- 
tion and debility during convalescence. 

My object in this lecture has been to lead you, in your clinical 
studies in the wards, and also in after-life, to rate aright the 
importance of the management of the digestive organs in dis- 
ease. I mean in disease generally, and not in that which specifi- 
cally affects those organs alone. And in future lectures on the 
same subject, I intend the descriptions I give of morbid phenom- 
ena, and the simple classes into which it is convenient to divide 
the impediments to digestion, to apply equally, whether they are 
alone and give a name to the illness, or whether they are united 
to anatomical changes which afford ground for a more convenient 
generic designation. 

Do not be deceived by the expression, " merely symptomatic," 
sometimes applied to the derangements of digestion in phthisis, 
ansemia, amenorrhoea, dropsy, hysteria, &c, such as I have cited 
for illustration. All parts and functions of the body are so knit 
together to form the great circle of life, that their comparative 
value to individual existence is more a question of time than of 
power. The failure of any one shortens the days more or less, 
and a "mere symptom" is as often the immediate cause of death 
as an organic change or a pathological process is. 

I shall, in the five following lectures, give as concise a sketch 
as I can of the principal modes in which the function of digestion 
is deranged, either alone or in connection with other diseases, 
pointing out on the way what rational indications of treatment 
they afford. I shall afterward comment on some of the most 
important means used to effect our purpose, and point out their 
bearing upon rational medicine. 



LECTURE XLII. 

SLOW DIGESTION AND ACIDITY. 

Healthy digestion is easy, quick, and complete — Unhealthy diges- 
tion is painful, slow, and defective — Phenomena exhibited 
in unhealthy digestion — Heartburn — Acidity. 

{Extra course, St. Mary's, Summer Session, 1857.) 

Healthy digestion is easy, quick, and complete. There can 
be no excess of it, for food cannot be too easily, quickly, and 
completely converted into chyme and taken into the system, and 
there is no such thing as too much health. 

In ill health digestion is impaired in one or more of these 
qualities — it becomes painful, slow, defective. 

You may use Greek words, and call the above-named erring 
qualities of the digestion dyspepsia, bradypepsia, and apepsia ; 
only remember, that making the old adjectives into new sub- 
stantives adds no whit to our knowledge, and unless care is 
taken, runs some risk of being a stumbling-block to its progress. 

For when we have in this way given a proper name with a 
capital letter, we are apt to think we have defined an individual 
and active motive power, instead of what is really the deficiency 
of a function, and thus we fall into the errors of our forefathers, 
whose dangerous aims at destroying their abstract foe the " Dis- 
ease," instead of restoring the existing patient, led to so much 
bad practice in the generation now passing away. I shall use 
the English adjectives, but first I will say shortly what I mean 
by them in this connection. 

Painful digestion may be, and often is, both defective and 



514 SLOW DIGESTION AND ACIDITY. 

slow ; but, on the other hand, it not unfrequently also is com- 
plete and performed with sufficient quickness. All that is in- 
tended by the word is to express that it is accompanied, at some 
stage of its progress, by feelings varying from slight discomfort 
to absolute torture. 

By slow digestion, I mean that the act in some part of the 
alimentary canal is not completed by the time when the conve- 
nience of the individual and of society require that it should be 
completed. The stomach, for instance, may retain so much of 
a former meal that it is not in a fit state to receive the new one 
which is absolutely required for the sustenance of the body. 
This is generally indicated by a want of the natural appetite 
which arises when the upper portion of the digestive apparatus 
is ready to do its work, and, in chronic cases, by imperfect nutri- 
tion, anaemia, debility, &c. Or, if we attempt to force food too 
quickly on the unwilling stomach, we have chemical decomposi- 
tion and defective digestion as consequences. 

By defective digestion, I mean that food capable of nourishing 
the body cannot do so, from lack of certain changes which it 
should naturally undergo in the alimentary canal. It is passed 
from thence either unaltered or chemically decomposed. There 
are seen in the faeces, either by the naked eye or the microscope, 
lumps of muscular fiber, fat, starch, &c. ; or else the products of 
their decay, consisting of various obnoxious gases and acids, are 
developed in quantity subversive of comfort. 

The morbid phenomena accompanying these errors of the di- 
gestive function may be divided according as they occur during 
the first stage, that is, before the alimentary mass has passed the 
pylorus ; in the second stage, that is, during its passage along 
the small intestines; or, in the third stage, after the passage 
of the ilio-caecal nerve. Now remark, I do not call, and I wish 
you not to call, these phenomena diseases of the stomach, or of 
the intestines, or of the colon. They are not so, and must not 
be treated as such. The discomforts felt in the first stage, for 
example, may be due to organs far away from the stomach, — to the 
uterus, to the kidneys, to the teeth, — yet they may be called by 
the same names and treated by the same remedies as when they 



SLOW DIGESTION AND ACIDITY. 515 

are owing to anatomical changes in that part. So those of the 
second and third stage often are traceable not to anything wrong 
in the ilia or colon, but to excess of mucus or deficiency of pep- 
sine in the stomach. This is a consideration of much practical 
importance, for it much influences the treatment. 

In the first stage of digestion we may notice, as common phe- 
nomena, those generally known by the following names : 

Heartburn ; Acidity ; Weight ; Tightness (or distention) ; 
Oppression ; Wearing (or boring) pain ; Cramp (or spasm) ; 
Eructation ; Vomiting. 

I would commend to you these words rather than any new 
Greek or Latin compounds which profess to include them. 
Nine times out of ten the artificially manufactured terms are 
not nearly so accurate as those which have become defined by 
daily use. 

HEARTBURN 

is a sense of heat or cold (they are much the same) at the car- 
diac orifice of the stomach, running at intervals up the course 
of the gullet. 

From the effects which alkalies have in allaying temporarily 
this pain, there seems no doubt that it arises from the action 
of the acid contents of the stomach on the cardiac and oesopha- 
geal nerves. The gastric mucous membrane itself does not suffer 
from acids; it secretes them,* and bears them in contact for the 
remainder of the day without inconvenience. The gullet, too, 
will bear them for a short time; swallowing a mouthful of sour 
victuals or drink gives a healthy man no immediate inconve- 

* There appears no doubt about the gastric juice being secreted acid, and be- 
coming neutral only from admixture with saliva. See the recent experiments of 
Drs. Bidder, Schmidt, Griinewaldt, and Schroder, compared in my "Digestion 
and its Derangements," chap, iv, and " Experiments on Digestion," by Dr. F. G. 
Smith, Philadelphia, 1856. This last-named very valuable renewal of observa- 
tions on the patient with gastric fistula, formerly a servant of Dr. Beaumont's, 
seems to show pretty conclusively that in the human subject the acid secreted 
is not hydrochloric, but probably lactic. The origin of the finding hydrochloric 
acid in gastric juice is that the lactic acid fermentation decomposes the chloride 
of sodium contained in all animal secretions. 



%\Q SLOW DIGESTION AND ACIDITY. 

nience ; but a continued exposure becomes painful in close pro- 
portion to its length, as may be easily tried by pouring down 
such articles slowly for a short time, whereby pain will be pro- 
duced even in the most healthy. 

Heartburn, or pain from the action of acids on the cardiac 
end of the oesophageal plexus, may arise in three ways : 

1st. By oversensitiveness of the nerves. 

2d. By too long exposure to the acids of digestion. 

3d. By too much acid being formed. 

(1st.) By oversensitiveness of these nerves (Overfeeling, hyper- 
aesthesis*). This is sometimes, but not always, accompanied by 
oversensitiveness in other parts of the body, and is the form of 
heartburn which weak, nervous, hysterical persons suffer from. 
It comes on almost immediately after eating, directly the con- 
tents of the stomach have begun to assume that degree of acidity 
which is natural and necessary to them. If vomiting does not 
occur, it continues till they have become neutralized either by 
the saliva which usually flows abundantly down the oesophagus, 
or by taking some alkali, or by the moving on of the mass toward 
the pylorus. 

The worst of this neutralization, natural or artificial, is that 
a good deal of the albuminoid food remains undigested. It is 
absolutely requisite for its solution by the gastric juice that it 
should be acid while in the stomach; and if this natural acidity 
is prevented, because it happens to be painful to the oversensi- 
tive nerves, the peptic solvent cannot act. Thus the digestion, 
from being painful, is made defective also. 

A peculiarity of heartburn from oversensitiveness, which often 
is a great assistance to the diagnosis, is that one kind of food 
brings it on as much as another; just in the same way as the 
peculiar grinding pain of gastric ulcer (which will be spoken of in 
a future lecture) is frequently to be distinguished by there being 
so little difference felt in the effect of different articles of diet. 

* Here is a flagrant example of the confusion attendant on coining words. 
Hypereesthesis is used now in writing and speaking, with seeming propriety, 
for morbid excesses of sensation; but so lately as 1831 it is defined in Hooper's 
Dictionary, "error of appetite." 



SLOW DIGESTION AND ACIDITY. 517 

It is to be observed, also, that it is very often worse after the 
early than after the later meals, even though the dietary should 
be more sparing and more digestible. Indeed, in private prac- 
tice, where one sees lighter diseases than those in hospital 
wards, I have notes of several patients who have eaten dinners 
and suppers without distress, but who invariably suffered after 
breakfast. 

This form of heartburn usually occurs in nervous, sensitive 
persons, whether their state of system is congenital, or induced 
by outward circumstances. Any untoward condition of the parts 
supplied by the abdominal plexuses of sympathetic nerves often 
brings it on. Tumors of the uterus or pregnancy are a very 
common cause, and excessive or painful menstruation often in- 
duces it in the female; and in the male I have known it brought 
on by piles and by mere constipation. It is often accompanied 
by vomiting in persons who have a tendency thereto. In these 
cases you have an opportunity of examining the contents of the 
stomach, and confirming what I stated about their being in a 
normal condition, by no means overacid or otherwise unnatural. 
Overanxiety, watching, harassing mental emotions, and, in 
short, all external circumstances which cause oversensitiveness, 
induce this state of digestion. Local pressure on the epigastrium 
will also fix the disorder in that part. It is curious that while 
the ordinary nerves of feeling appear blunted by pressure and 
the frequent repetition of excitement, the sympathetic should be 
made more sensitive. Such, however, seems to.be the case with 
the epigastric plexus, to judge by the frequency with which this 
form of heartburn occurs in shoemakers, needle-women, clerks, 
and others whose ordinary occupations involve pressure on the 
pit of the stomach. 

As anaemia, debility, and occupations which occasion them, 
induce this heartburn, so it too will react, and increase them, or 
even bring them on. An impoverished stomach, thus unable to 
bear the labor of digestion, becomes poorer still from defective 
supply. That happens in the human body which Martial com- 
plains of as one of the vices of civilization — those most in want 
gather least wealth — "Dantur opes nulli nunc nisi divitibus." 



518 SLOW DIGESTION AND ARIDITY. 

But at the same time a slight change of habits, or slight relief 
from medicine, will equally react beneficially, and commence a 
march toward health with unhoped quickness. 

It will also, too, sometimes be associated with, and very much 
aggravate, the intermittent headache of marsh miasma, causing 
" brow-ague " to begin after the mid-day meal, instead of at other 
times. 

The suddenness with which heartburn will come on, and the 
rapidity with which it often goes away, is a great help to the 
diagnosis of the nervous origin of this affection, and it is also a 
great encouragement to the physician to promise relief to the 
sufferer. 

The sketch I have given of the physiology of this disorder 
points out the treatment most likety to be successful in the end. 
The aim must be, not to neutralize the acid, but to blunt the 
oversensitiveness of the nerves. This can be done, first, directly, 
but temporarily, by medicines known experimentally to have 
that effect on sensitive nerves ; secondly, indirectly, by strength- 
ening the whole system, so that those nerves along with it may 
become hardier to bear the brunt of their necessary duties. 

You have seen me often in the wards of this hospital begin 
the treatment with hydrocyanic acid and bismuth, and in a few 
days commence the use of steel, or valerian, or quinine. The 
benefit found from the first-named drugs is decided, indeed, but 
it is temporary, and few cases will get permanently well unless 
they are followed up by the tonics. At the same time there is 
a great advantage, still greater in private than in hospital prac- 
tice, in commencing with a medicine whose influence is imme- 
diate, and which will gain the confidence of your patient for any 
future plan you may adopt. 

Where brow-ague or any other form of neuralgia is concomit- 
ant or consequent, you will best treat it by four or five grains 
of quinine, taken an hour and a half before the meal after which 
it comes on — that is to say, in most instances, the mid-day meal. 
I have found this treatment of the neuralgia more effective than 
that by iron, the quinine curing not only more certainly, but 
more rapidly. 



SLOW DIGESTION AND ACIDITY. 519 

Sponging the body with cold sea-water, and the shower-bath, 
are often most useful remedies, acting doubtless in a great 
measure through the general system. But cold sponging or 
douching the epigastrium, which may be easily managed sitting 
in a hip-bath, appears to have a special local action, and cer- 
tainly does still more good. 

The tonics which must follow up this special treatment may 
be varied according to the case and the patient's convenience ; 
but, as a general rule, I find none do better than iron. 

(2d.) By too long exposure to the acids of digestion. Many 
influences, which in moderation are rather pleasant than other- 
wise to the sensory nerves, become exquisitely painful when 
long continued. For example, the immersion of a limb in water 
a few degrees below the temperature of the air is not disagree- 
able, and may be kept on with intermissions for any length of 
time ; but it becomes absolute torture if persisted in without an 
interval of rest. So, in many cases, a sluggish stomach, in 
which the progress of digestion is too slow, causes the cardiac 
orifice to be so long steeped with acid that it becomes painful, 
though a proper exposure for the natural length of time could 
be borne with ease. Just in the same way a continued dribbling 
of faeces will make the anus sore — a continual running from the 
nose excoriate the nares, &c. 

This form of heartburn never like the first comes on immedi- 
ately after eating. It often does not occur till four or more 
hours are passed; in fact, till the period at which the stomach 
ought to be nearly empty, and preparing for another meal. But 
the most usual time is an hour after eating. Its long continu- 
ance will, however, be apt to induce that tenderness of nerves 
which constitutes the first form, so that it will approach nearer 
and nearer to the time of meals, till at last it commences imme- 
diately. It differs, though not invariably, in one important 
diagnostic peculiarity: that it is more common after the later 
than the earlier meals. It will also, like the first form, bring 
on nervous headache, and occasionally a decided intermittent 
neuralgia, aggravated by the same causes, and removable by the 
same remedies as that arising from marsh miasma. Even if the 



520 SLOW DIGESTION AND ARIDITY. 

meal should be omitted, this headache will still come on ; but if 
the time of the meal be changed, the time of the headache will 
change with it. 

Though the oesophagus is relaxed so as to admit of some re- 
gurgitation, yet what comes up is seldom more than air, usually 
of a neutral inoffensive character, and not in the great quantities 
and with the explosive force which marks the formation of car- 
bonic acid by fermentation in the stomach. 

The persons in whom it occurs are active men of business, 
literary laborers, clerks, overthoughtful and overcareful. But 
when once acquired, it is very apt to persist in spite of a change 
in the mode of life. I have had as patients thus affected many 
farmers and country gentlemen who had suffered since youth, 
though living with little apparent care or intellectual occupation. 

As before mentioned, it may lead to the first form of heart- 
burn: but in symptoms, pathology, and treatment it may be 
considered as a transition from it to the next in order. And I 
shall therefore postpone speaking of the indications it affords till 
I have brought before you the heartburn which arises, 

(3dly.) By too much acid being formed. To this the name of 
"acidity" is applied with propriety, because there really is an 
excess of acid. It comes on at a period more distant from the 
time of meals than the last kind, and may be considered, in some 
respects, as a further stage of it. The pain, however, is much 
less intense in general, sometimes so slight as to cause scarce 
any inconvenience. But the regurgitations are much greater; 
sometimes true vomiting occurs, distinguished by spasmodic action 
of the diaphragm ; sometimes only a teaspoonful of intensely sour 
liquid comes up, roughening the teeth, and bringing tears into 
the eyes; sometimes a gaseous acid (acetic and butyric) is belched 
up spasmodically; sometimes it oozes up gradually, and its pres- 
ence is shown by the saliva and breath being sour to the taste 
and smell. 

These peculiarities will suffice to distinguish between " acidity " 
or heartburn from real excess of acid, and those forms previously 
named where the excess is only apparent. A further test may 
be found in the action of remedies: a small dose of alkali, a grain 



SLOW DIGESTION AND ACIDITY. 521 

or two of soda or potash will be sufficient to appease them; 
whereas, in this case, a very considerable dose is required. 

Acidity is often misunderstood. I have heard it spoken of as 
"an excess of gastric juice," "excess of action in the stomach;" 
that is to say, too much of a vital act, too much life. Such a 
mode of speaking, if it leads to anything, must lead to faulty 
thinking and bad treatment. 

Instead of being an excess of gastric juice, it is itself a proof 
of deficiency. You may prove by experiments on artificial diges- 
tion, that an increase in the quantity of the solvent secretion 
quickens the solution of albumen. You will find, for instance, 
that the amount of pepsine contained in twenty grains of Bou- 
dault's powder will dissolve a piece of hard-boiled white of egg 
much sooner than five grains. The same thing would of course 
happen in the stomach ; were there more gastric juice there would 
be quicker digestion. But in "acidity" such is notoriously not 
the case; the aliments lie for a long time in the upper part of 
the digestive canal, and often are, after all, passed undissolved 
in the feces. It is a chemical act of decomposition directly 
opposed to the vital act of digestion. 

I call a "vital" act any which forms part of the great circle 
of life, such as is the conversion in the stomach of albumen, 
previously incapable of solution and absorption, into peptone 
capable of entering the circulation. Now, when this vital act 
of conversion is carried on with rapidity by a stomach making 
abundance of gastric juice strong in pepsine, then chemical de- 
composition is prevented; nay, it is even arrested after it has 
commenced, as may be seen by putrid meat not becoming more 
but less putrid as it passes through the body of a healthy animal. 
But when the conversion is slowly or imperfectly performed, then 
chemical change has time to take place, and does so very soon, 
being favored by the heat, moisture, and animal matter in a state 
of change. If the food remain too long without becoming chyme, 
the protein compounds putrefy with extreme rapidity under such 
circumstances. 

Compare this white of egg which has been immersed in saliva 
at the temperature of 100° Fahr. for twenty hours, with anothe 
34 



522 SLOW DIGESTION AND ACIDITY. 

portion from the same egg kept the same time in distilled water. 
Your nose warns you of the difference directly; the first is in- 
tolerably fetid, the second quite sweet. 

[Experiments shown.) 
Exactly similar is the fate of undigested albuminoid matter, 
whether animal or vegetable, in contact with the mucous mem- 
branes inside the body. But how does that affect the case of 
acidity? Thus : I have in this beaker some syrup of grape sugar, 
quite neutral and natural. Here is some of the same which has 
been poured on a piece of putrefying albumen a few hours ago, 
and kept at the temperature of the body. You see that a piece 
of litmus paper I put in it is strongly reddened, showing the 
copious formation of lactic acid. In another beaker, the form- 
ation of butyric acid from fresh butter by the same means is 
shown to you. 

[Experiments shown.) 

Just so all the grape sugar and fat swallowed, when it meets 
in the stomach or intestines with decomposing animal food, re- 
maining in a mass or glued to the side by a too sticky mucus, 
ferments quickly throughout, and forms lactic and butyric acids 
in great quantity. 

Remember, the grape sugar swallowed means something much 
more important than merely the grape sugar eaten. See this 
boiled starch ; I heat some of it with the potassio-tartrate of 
copper, and there is no change in the blue color of the salt. 
Now I put some in my mouth, and hold it less than a minute. 

(Experiments shown.) 

See ! when it is again heated with potassio-tartrate of copper, 
the metal is precipitated, and shows by its brilliant yellow color 
an abundant quantity of sugar. The saliva, you see, begins to 
convert starch into sugar immediately ; very soon it will trans- 
form the whole mass. A mouthful of boiled starch which I held 
in my mouth for five minutes the other day showed afterward 
scarce a trace of starch remaining. As, even among meat-eat- 
ing nations, from half to five-sixths of the solid food consists of 



SLOW DIGESTION AND ACIDITY. 523 

starch,* it is evident that one of the most bulky contents of the 
stomach must be the sugar which has been made by the saliva 
out of amylaceous food. Here then is ample material for the 
formation of lactic acid to almost any amount. Add to this the 
oleaginous substances which it is impossible to avoid in any diet, 
and which, from being insoluble in water, constitute a pecu- 
liarly acrid and concentrated acid, and you will have no diffi- 
culty in accounting for acidity, without recurring to a theoreti- 
cal excess of gastric juice. Acidity then is an evidence of 
chemical, and therefore of decreased, vital action, a proof of in- 
complete digestion, of deficient activity in the stomach. 

On this rests the rationale of the hints for treatment which it 
gives. The way to cure it temporarily is to neutralize by alkalies 
the excess of acid which is formed. And this may be freely 
done without fear, of bad consequences ; for you are not likely 
by any reasonable dose to make it so far alkaline as to interfere 
with digestion. It is not in this form, where acid is really in 
excess, but in the first (or nervous) heartburn that alkalies do 
harm, for the reasons there stated. Where it arises simply 
from temporary debility induced by occasional gluttony, " the 
remorse of a guilty stomach," it may be left to cure itself. 
But a permanent cure can only be brought about by reagents 
which — 

(1st.) Strengthen the local power of the gastric solvent. 

(2d.) Augment its quantity. 

(3d.) Excite the peristaltic motions. 

The local power of the pepsine secreted, although in diminished 
quantity, may be much increased by neutralizing the saliva 
swallowed and collected in the stomach and oesophagus just 
before the meal. In laboratory experiments on artificial diges- 
tion, you will find that saliva arrests the solvent action of pep- 
sine in a close proportion to its amount. In the laboratory you 
may set the action at work again by acidifying the mixture, 
unless you have waited so long as to allow it to decompose. So 
too in the stomach, if you take it in time, you may free the 

* See the dietaries of soldiers, prisoners, laborers, and others, analyzed by Dr. 
Hildensheim in " Die Normai-Diat," p. 6, Berlin, 1856. 



524 SLOW DIGESTION AND ^CIDITY. 

pepsine from the alkaline saliva, and enable it to do its duty by 
adding acids. The best to select are those to which the viscera 
are most used, hydrochloric or lactic. A few drops of these 
taken immediately before meals will almost always have a most 
beneficial effect. 

The quantity of the gastric juice may be increased by supply- 
ing one of its most important constituents, water ; but in large 
quantity at the meal it is apt to dilute too much the sparing 
secretion, and hence it is better to direct the principal draughts 
to be taken half an hour afterward. An artificial gastric juice, 
in the shape of one of the new preparations of pepsine, may also 
be given if the acids are not sufficient ; but I prefer to try at 
first and get the patient to be his own pepsine maker. The 
colder the water the better ; for the low temperature acts as a 
tonic shower-bath to the local nerves, and removes the congestion 
of the blood-vessels, while at the same time it never quite stops 
digestion, and soon acquires heat enough to let it go on with full 
rapidity.* 

Your patient will perhaps think that you are blowing hot and 
cold, or rendering inert your own treatment, by ordering acids 
at one time and alkalies at another ; so you will find it a wise 
plan to give him a short physiological lecture on the subject, 
explaining the reason of your procedure. You may explain also 
that the acids given as medicine do something more than in the 
laboratory : they stimulate the mucous membrane, and so actually 
increase the quantity of secretion while they increase its power. 
You need not have the fear, which I have heard some express, 
that the use of these substitutes for the natural constituents of 
the gastric juice, or rather the supply of that which ought to 
exist in the gastric juice, will teach the stomach to be lazy — as 
doing a servant's work for him makes him less equal to doing it 
himself. On the contrary, the new vigor put into the system by 

* That cold retards the action of the gastric solvent is shown by some ex- 
periments on artificial digestion 1 published in " The Lancet" of May 23, 1857. 
But at the same time it does not stop it. Even the freezing temperature does 
not entirely do that, as is proved by Drs. Bidder and Schmidt. " Die Ver- 
dauungssafte," Exp. ix, 1, 2 ; x, 1 ; xvi ; xvii. This is a comfort to the admirers 
of ices. 



SLOW DIGESTION AND ACIDITY. 525 

the healthier and more copious chyme that is formed, renders 
the organ more active ; so that it soon is enabled to go on secret- 
ing for itself what is wanted, and to do without the artificial sub- 
stitute. Do not, therefore let patients fancy that they might get 
into a habit of taking these medicines, so as to be obliged to 
continue or to increase the dose. If they derive benefit from 
them, they will be able soon to leave them off. 

The action of the peristaltic muscles of the stomach can be 
excited by most of the drugs which act as purgatives. But un- 
fortunately, in the great majority of gastric complaints, purga- 
tives are decidedly injurious, so that the good done to the stomach 
is overbalanced by the injury done elsewhere. The least hurtful 
are rhubarb and aloes ; but even they somewhat impede the 
digestion in many persons who take them as a dinner pill. A 
better expedient is strychnine. Its small bulk causes it to be 
quickly absorbed, and to act locally on the stomach alone with- 
out affecting the rest of the system ; so that where common 
caution is observed, I have never found it necessary to leave it 
off on account of the occurrence of specific spasmodic effects ; at 
the same time its beneficial influence is most marked, and in 
many instances it acts as a bitter tonic also, increasing the 
appetite and spirits. 



LECTURE XLIII. 

PAIN IN THE STOMACH. 

Local weight, tightness, distention, dependent on excessive secretion 
of mucus — Gastric catarrh, acute and chronic. 

[Extra course, St. Mary's, Summer Session, 1857.) 

Weight, Tightness, Distention, sometimes a feeling ex- 
pressed as of being "blown out with wind," while on examina- 
tion the epigastrium is found not more tumid than that of a 
healthy person digesting, are modifications of a sensation pro- 
duced in the nerves of the stomach itself. 

(1.) Alone. — Where the sensation exists alone, unaccompanied 
by soreness, by pain on pressure, or by decided pain immediately 
after eating, it is possible to judge of the real meaning of the 
phenomenon. But in complicated cases the difficulties presented 
are very great. Putting aside for the nonce these latter, and 
looking only to simple examples, I have come to the conclusion 
that it denotes simply the presence of an excessive amount of 
mucus in the stomach. 

Like other mucous membranes, that of the stomach may be 
affected acutely or chronically. The first case may be called 
" gastric catarrh;" the second, " mucous flux." Both are liable 
to be followed by vomiting, which relieves temporarily the dis- 
tress, and which in the acute form constitutes the most ordinary 
form of u bilious attack," so called from the bile which the action 
of the diaphragm in vomiting causes to regurgitate along with 
the contents of the stomach. When not. rejected by vomiting, 
the aliments are so enveloped in mucus, that they cannot be 



PAIN IN THE STOMACH. 527 

acted upon by the gastric juice, and are passed very little 
changed into the bowels, where they are liable to ferment, and 
by their acidity cause diarrhoea, flatulence, and sometimes a 
copious discharge of mucus from the bowels. This latter result 
is more common in acute than in chronic cases, where the 
motions are often infrequent and irregular, and exhibit unformed 
or scybalous faeces. 

When vomiting occurs, the ejected matters are mixed with so 
much mucus that there is no difficulty in making the diagnosis ; 
but where it does not, the case is liable to be mistaken for one 
of disease of the bowels, on account of the flatulence and mucous 
diarrhoea. Certainty of diagnosis can in such cases be obtained 
only by the administration of an emetic, which brings the source 
of the evil into the light of day. 

In acute cases this excess of mucus is often accompanied by 
very intense headache, but in chronic it seldom goes beyond a 
feeling of stupidity. Flushing of the face, and heat at the back 
of the eyes, are also nervous symptoms dependent upon the 
chronic condition, and seem quite independent of any disturb- 
ance of the circulation. 

" Acute catarrh of the stomach," like all other catarrhs, is 
excited by external, and often by epidemic influences. Changes 
of temperature are its most frequent cause. Bu still, as in other 
catarrhs, the cause must have been a special reason in the indi- 
vidual for selecting one mucous membrane rather than another. 
And since the naturally warm position of the stomach, aided by 
the usual habits of dress, guard it very efficiently against ordi- 
nary variations of the weather, the idiosyncrasy of the individual 
has a preponderating influence on its production, and often leads 
the others to be overlooked. But in the prevention of the com- 
plaint more is to be done by attending to these special reasons, 
and by protecting the stomach against such deleterious agents as 
the habits of the patient expose it to, than by trying to alter the 
diathesis of his body. 

On the other hand, the mucous flux is much less dependent on 
external circumstances, and much more on organic changes either 
in the stomach itself or some other viscus. Tubercles in the 



528 PAIN IN THE STOMACH. 

lungs, emphysema, chronic bronchitis, and enlarged heart, 
oftenest produce it, and it is associated with cancerous, tuber- 
cular, and inflammatory affections of neighboring parts, but 
alone it is rare. In this it resembles bronchial flux or chronic 
bronchitis.* 

(2.) With soreness on pressure, more especially if the soreness 
exist also when the stomach is empty, or if accompanied by a 
decided pain arising from the ingestion of food, it denotes that 
the secretion of mucus depends on some local inflammation or 
ulceration of a chronic character in the mucous membrane. Where 
a tumor can be felt, the probability is that it is of a cancerous 
nature. Where there has been bloody vomiting, the diagnosis of 
ulcer, cancerous or non-cancerous, is almost certain. 

I incline to think that the peculiar sensation just described 
depends on the general state of the mucous membrane, and not 
on the local injury to one part or another of the stomach. My 
reason for thinking so is that it is capable of so much relief by 
medicines even in patients where the spot anatomically altered 
is found afterward to have been gradually progressing. Some of 
you may remember a man who lay in Albert Ward during 
the greater part of a year, with rapidly growing cancer of the 
liver and pylorus. In spite of a continuous increase of his neces- 
sarily fatal tumors, the sense of distention and weight after food 

* In 25 post-mortem instances of excess of mucus adherent to the walls of the 
stomach — 

6 had tubercles or vomica? in the lungs as chief cause of death ; 
4 had diseased hearts as chief cause of death ; 

1 had oedema pulmonum or emphysema observed after death, or chronic 
cough-observed during life, as chief cause of death. 
In the above 1 V it may be considered as self-evident that there was an in- 
creased secretion of mucus from the bronchi as well as from the stomach. 
Of the remainder — 

4 had diseased kidneys as chief cause of death; 
1 pneumonia (in both of which chronic cough was not unlikely); 
1 had cancerous ; and 
1 tubercular disease of the peritoneum ; 

1, a child of four months, had acute inflammation of the bowels, and the 
mucus was an evidence of gastric fever, not of chronic flux. 
(See " Digestion and its Derangements," by the author, p. 353, with the refer- 
a ces to Dr. Jones' paper.) 



PAIN IN THE STOMACH. 529 

diminished, the patient rarely vomited his meals, and was able 
to eat largely. His being able to take a large quantity of nutri- 
ment much prolonged his life, and his illness on the whole was 
not one of much distress. So you see that the treatment of even 
necessarily fatal cases is capable of adding much to the comfort 
of our fellow-men, and is well worth the thought and attention 
of a serious mind. 

It may be observed, that where distention with soreness is de- 
pendent on local inflammation of the stomach, the pain is constant, 
at no time entirely absent, though increased by the ingestion of 
food. You may see a well-marked case followed out in " Case- 
book" xxxix, p. 424 (where the complete cure seems to show 
that there was no ulceration), and several others scattered through 
the books and indexed as " haematemesis" (where the throwing 
up of blood seemed to indicate that lesion), in all of which the 
discomfort is described as never quite wanting. 

The excessive secretion of mucus in the stomach, whether 
arising from ulceration of the membrane, from chronic inflam- 
mation of it or neighboring parts, from adhesion of the peri- 
toneum restricting the peristaltic movements, from simple de- 
generative thickening of the secreting structure, from cancer, 
from external pressure (as in the case of cobblers or tight-laced 
women), is indicated by the sense of distention above named. 
But the evil rarely stops here. The gastric juice that is poured 
out cannot penetrate the slimy layer that envelops, as in a bag, 
the mass of aliment, which consequently ferments and produces 
all the evils arising from chemical decomposition in the stomach. 
And if the solvent secretion could get to them, it would be 
neutralized by the alkali of the mucus, and so rendered incapable 
of dissolving albumen. Hence heartburn and acidity arise, as 
before explained ; and hence, in some constitutions, vomiting, in 
others a passage of the fermenting mass into the bowels, and 
diarrhoea. 

Mucus itself appears peculiarly incapable of being digested. 
When children with catarrhal coughs swallow their bronchial 
secretion, you may often find it unaltered in the stools. If you 
try to dissolve it in artificial gastric juice in the laboratory, 



530 PAIN IN THE STOMACH. 

small lumps undergo no change after several days. Still more, 
when the extensive surface of the stomach secretes a large ad- 
herent mass of a peculiarly stringy and firm description, it is 
often passed in large quantities through the bowels, and induces 
a suspicion that some part of the latter organs are the seat of 
the evil. And in truth the diagnosis is not easy. The best 
guide to it is the observation of the contents of these masses of 
mucus — if you find enveloped in the glairy slime merely brown 
granular matter, hairs, threads, the cellular tissue and husks of 
plants, bits of gristle or skin, bile, or anything developing the 
natural smell of faeces, then you may fairly conclude that the 
mucus comes from the bowel ; but if there are bits of food un- 
colored by bile— if, instead of smelling like faeces, they are 
putrid, or exhale an odor like vomit, it is certain that some, and 
probably the greater part, of the mischief lies in the stomach. 
Thus you see that the digestive function, in the cases we are now 
considering, is "painful" and "imperfect," but by no means 
necessarily "slow;" indeed, in many cases, the little digestion 
that goes on is performed, with too great quickness. 

The indications for treatment derived from a mucous condition 
of stomach are as follows : First, it must be remembered that it 
is not only the evidence of disease (like the flow from the nose 
in nasal catarrh, for example, which does no injury after it has 
once flowed out), but it is also the cause of further evil, and 
therefore it must be directly restrained by astringents. 

Secondly, the place of the patient's own gastric juice, which 
cannot get at the food, must be supplied by artificial solution of 
their aliments, and their decomposition must be prevented. 

Thirdly, alterative diet and medicines, and local counter-irri- 
tants must be used to relieve the congested or degenerated state 
of the organ at fault; especially in cases complicated with pain. 

Of astringents, I have found none act more directly than 
kino; and where there is pain at the cardiac extremity of the 
stomach, heartburn, or pyrosis, the conjunction of opium with 
it, as in the pulvis kino compositus of the pharmacopoeia, in- 
creases its efficiency. Larger doses of opium, however, in quan- 
tities sufficient to produce soporific effects, cause headache. A 



PAIN IN THE STOMACH. 531 

good test of the extent to which it is desirable to give astringents 
may be found in their action over the bowels. While doing 
good they cause no constipation; and, in some instances, even 
relieve that symptom by removing the general state of irrita- 
bility and discomfort, and by checking the discharge of mucus; 
so that it may be made a rule to continue them only so long as 
they do not constipate the bowels. 

Nitrate of silver is a very powerful astringent. But it is of 
no use unless you prevent the salt from being decomposed and 
converted by the chloride of sodium of the mouth into the inert 
chloride of silver. The best mode of securing it is to cover the 
pill thickly with gelatine, so that it remains undissolved until it 
gets to the right seat of action. 

The sulphate of iron is also a very valuable astringent, espe- 
cially in anaemic cases. I have found it a good plan to com- 
mence with the nitrate of silver; and, when obliged to leave that 
off for fear of turning the complexion black, to commence the 
iron, and continue that until complete re-establishment of health. 
Ferruginous waters, especially those containing the sulphate 
(such as the Moffat and Hartfell chalybeates), or any others 
where the metal is made into sulphate by the addition of a few 
drops of sulphuric acid, will, of course, be equally beneficial — 
indeed, often more so from the addition of change of air and 
scene. 

Another form of iron which I have found very useful in gastric 
cases is u iron alum," but I cannot detect any difference in its 
action from the ordinary copperas above recommended. 

Gallic acid is also useful, if a variety of astringents is re- 
quired. But, to say the truth, I have been unable to detect 
any advantage which one medicine of this sort has over another, 
and think the only use in having a long list is to be able to ring 
the changes upon them, to prevent the patient wearying of uni- 
formity. 

The arrested solution of the aliments may be partially com- 
pensated for by a diet of milk guarded from coagulation by 
lime-water, so as to postpone its digestion to the intestines. The 
avoidance of such articles as are apt to form a solid mass will 



532 PAIN IN THE STOMACH. 

do much ; and for this reason pastry, new bread, and hard meat, 
or fish, must be strictly proscribed. But the most complete sub- 
stitute for the patient's own natural secretion is pepsine arti- 
ficially prepared. It enables solid albuminous food to be taken 
without distress, increases the appetite, and raises the strength. 
In the milder cases, lactic acid, taken before food, is sufficient. 

The most efficient agent in preventing the decomposition of 
albuminous food (evinced by fetid evacuations, acidity, &c), is 
sulphurous acid combined with soda. There are two forms of 
this salt, the sulphite and hyposulphite. Of these, the former 
contains most sulphurous acid, and certainly does the work re- 
quired of it most readily. But then it has the bad quality of 
completely destroying the potency of gastric juice at the same 
time, so that while you are preventing the chemical decomposi- 
tion you are also preventing the vital digestion. The hyposul- 
phite has not this pernicious effect, and may also, from its less 
nauseous taste, be given in larger doses, so that by its means you 
are able to do the good without the harm.* 

By "alterative" diet I mean a restricted supply of nutriment, 
so that the destruction of effete tissues should somewhat exceed 
the supply. This for a short period seems beneficial in cases 
where there is an organic change in the tissue of the stomach 
itself. But the treatment must not be carried too far: a week 
is, perhaps, the extreme period to which the starving system 
should be carried; if it does not do the good expected in that 
time, it never will. 

The same cases are benefited by counter-irritants, such as 
leeching, blistering, and long-continued water-dressings to the 
epigastrium. The advantages of the first are, that their appli- 
cation is soonest over, and gives relief most rapidly, while at the 
same time it does not prevent the use soon after of the other 
local remedies. The fear that this little loss of blood will lower 
the patient is theoretical; for the increased power of digestion 
adds twice as much blood and flesh as the leeches can suck away. 
In "Case-book" No. li, page 223, you will find the case of a 

* See "Experiments on Artificial Digestion," by Dr. Chambers, in "The 
Lancet" of the 23d of May, 1857. 



PAIN IN THE STOMACH. 533 

patient of mine who was leeched on the epigastrium for some 
time every other night, yet gained twenty-one pounds in weight 
during her six weeks' stay in the hospital, so great was the relief 
afforded in her form of indigestion. The advantage of the wet' 
compresses as a counter-irritant is, that they do least harm, 
though at the same time it must be confessed that they do least 
good, and are scarcely adapted for severe cases. However, in 
the milder, especially where the person is not so ill as to be kept 
from ordinary business, this method of accomplishing your object 
is very convenient. 

The use of mercury is beneficial just in about the same degree 
as the alterative diet above mentioned: immediately it has begun 
to have any good effect it must be left off, or it will begin to do 
harm. It is excellent as an inaugurator or introducer of good, 
but it does not carry it on without the evil results showing them- 
selves. The utmost care must be taken that it does not specific- 
ally affect the system, or purge. As a universal rule, purgatives, 
and especially mercurial purgatives, do harm. 

"Oppression" is often complained of at the same time with 
the weight, tightness, or distention at the epigastrium. But it 
means something more, and is by no means identical. Indeed, in 
those worst cases of mucus on the stomach, which relieve them- 
selves by vomiting or by rapidly passing on with the alimentary 
mass, there is no oppression at all. On the other hand, there 
are frequent instances of much discomfort where the patients do 
not at all assent to the description of a weight at the pit of the 
stomach. That is a purely local feeling, referred, in a former 
part of this lecture, to the local nerves ; whereas this indicates 
a general feeling of morbid lassitude and physical incapacity 
throughout the whole body. There is a confusion of ideas, some- 
times an unnatural sleep, sometimes faintness, irregular nervous 
action, such as flushings of the face, palpitation of the heart, 
fidgets, twitchings, or cramp. 

As I said before, these are often the accompaniments of gastric 
mucous flux, but at the same time they often exist without it ; 
and, indeed, almost anybody may bring them on by getting very 
tired "and then eating largely. If vomiting occurs, you see no 



534 PAIN IN THE STOMACH. 

mucus in the egesta, but simply the food last taken unaltered in 
quality or appearance. Digestion is more than slow, it has com- 
pletely stopped. 

Oppression shows an exhausted condition of the muscular and 
nervous system of the stomach. The peristaltic motion is null 
from want of power. The causes usually are those which exhaust 
the nervous energies without stimulating the powers of life, such 
as prolonged and severe intellectual labor, annoyance of mind, 
and overstrained attention. Temporarily, and in persons previ- 
ously disposed, mere corporeal exertion may bring it on; but 
this form of depression usually works its own cure, and does not 
become a chronic habit; for the excessive bodily toil either causes 
a reactive stage of increased nutrition, or so much exhausts the 
voluntary muscular system that it cannot be continued. 

This view of the pathology of the disorder obviously suggests 
the appropriate treatment, which is, to tone and invigorate the 
involuntary muscles of the stomach. I have found no remedy 
do this so invariably as strychnine. Should anaemia be present, 
iron— if heartburn, acidity, or waterbrash be joined, then bismuth 
can be added ; but where the symptom named exists alone, or 
predominates above the others, still more, if bark, iron, or other 
tonics in any way disagree, nothing affords such satisfactory re- 
sults as the alkaloid principle of nux vomica above named. 

Wearing or boring pain commences gradually soon after 
food ; it is confined to the epigastrium, or extends itself over 
the abdomen, and does not run up the oesophagus like heartburn. 
It sometimes is relieved by vomiting, and if not, continues with 
more or less intensity till the stomach empties itself through 
the pylorus. The pain is increased by pressure, very often not 
immediately, but in the course of a minute or two, as if the 
sluggish sensation of the part took some time to appreciate the 
injury. 

Boring pain is nearly always sufficient to rouse a suspicion of 
ulceration ; even cancer does not cause it, so long as the mucous 
membrane be whole. The suspicion is strengthened if weight 
and tightness of epigastrium be present to indicate the excessive 
secretion of mucus which usually accompanies chronic ulcer ; and 



PAIN IN THE STOMACH. 535 

the diagnosis is further confirmed by the occurrence of bloody 
vomiting. 

It can seldom be removed by internal remedies. Those which 
do it most good are bismuth, opium, and kino ; but counter- 
irritants to the external surface of its seat, leeches, blisters, con- 
tinuous poultices, mercurial and opiate inunctions, are of much 
more marked benefit. 

It is in these cases especially that the failing organ requires 
to be spared work. The best dietetic substance is milk made 
alkaline with lime or soda-water, given in small quantities as 
frequently as possible. Next to that, a mouthful of mutton-chop 
at a time, with a dose of pepsine to digest it. Meals are painful, 
your patient tells you, so advise none to be taken, but a con- 
tinuous sparing supply of such food as may pass through the 
stomach without distending it, and be digested by the small 
trickling of peptic juice w T hich there is in the stomach and bowels. 
The chief object of the lime-water is to prevent the milk forming 
a large curd, but it also may be a sedative to the raw surface, 
just as it is to a blistered or burnt skin. 

Cramp or spasmodic pain in the epigastrium appears to arise 
from the pyloric sphincter. It is often accompanied by cramps 
in the neighboring and remote muscles, thus affording an indi- 
cation of the tissue in which its seat is to be looked for. It occurs 
chiefly in old persons, during the latter period of the stay of the 
food in the stomach, and does not show any organic disorder of 
the part. A moderate dose of an anaesthetic stimulant is the best 
mode of relief: the domestic remedy of a thimbleful of brandy 
with two drops of laudanum is about the most efficient that can 
be administered. 



LECTURE XLIV. 

ERUCTATION AND VOMITING. 

Anatomy and physiology of Eructation — Relaxation of oesopha- 
gus — Spasm — Analyses of gases by chemists — Deductions 
therefrom— Secretion of air by mucous membrane (?) — De- 
fective absorption — Decomposition of food — Fermentation 
prevented by acidity— Classification of morbid states in 
which eructation occurs — Indications of treatment in the 
several classes — Antacids — Astringents — Valerian — Am- 
monia — Sulphurous acid — Charcoal — Vomiting — Causes 
of — Indications afforded by the contents of the vomit — 
Remedies for — Hydrocyanic acid — Carbonate of magnesia 
— Opium — Chloroform — Leeches — Lime-water and milk — 
Brandy — Creasote— Valerianate of zinc— Ice — Possibility 
of starvation from vomiting of a purely functional charac- 
ter — Sea-sickness and its remedies. 

{Extra course, St. Marys, Summer Session, 1857.) 

Eructation is the passage upward through the oesophagus of 
air contained in the stomach. It must be remarked that the 
gaseous contents of the hollow viscera are differently circum- 
stanced from the liquids and solids ; their great expansibility by 
heat, and their low specific gravity, give them an inherent force 
which enables them to find their way out without any aid from 
the muscular system. There is no fluid so light but it requires 
the action of the expiratory muscles to expel it from the stomach, 
whereas no gas is so heavy but that, when warmed by the body, 
it will not rise through the oesophagus directly that tube is re- 
laxed. 



ERUCTATION AND VOMITING. 537 

The first condition of eructation is the relaxed and open state 
of the cardiac end of the gullet. The air, instead of being re- 
tained by the natural contraction of this powerful sphincter, 
finds its way upward in greater or smaller quantity. The pas- 
sage of the bubble toward the mouth almost always, except in 
completely paralytic patients, causes a reaction, and by the time 
it gets to the fauces it is compressed by the stimulated muscles, 
and expelled with considerable force. Hence the noise is greater 
than is caused by the mere bubbling of air up the gullet, such as 
you produce in moving a dead body. There is a compound of re- 
laxation and reactionary spasm, the former taking the initiative. 

The analyses of the gas contained in the stomach, by Chevreul 
and Chevillot, show that more than four-fifths of it is atmospheric 
air and the rest carbonic acid in much less proportion than in 
the breath which is passing out of the mouth by expiration.* So 
that we have clearly not to seek far for a source of the air ; it is 
evidently swallowed with the food and saliva in the great ma- 
jority of cases. Some persons also have a trick of half-consciously 
swallowing air, like crib-biting horses, especially when suffering 
from some uneasiness in the digestive organs ; and in the par- 
oxysms of sobbing, of hysteria, and of epilepsy, large quantities 
are gulped down. And it is not impossible that gas might be 
secreted by the mucous membrane, though I am not aware of 
any case that proves the occurrence. 

Another morbid condition that helps to produce the flatulent 
collection of gases is defective absorption. In health gases are 
very easily absorbed by the alimentary canal. It is the normal 
thing for the abdomen to be dilated during digestion with several 
pints of air, which disappear in a short time without passing up- 
ward or downward. To be convinced of this fact is exceedingly 
easy, by observing the extent to which the parietes of the belly 
are distended and the descent of the diaphragm is impeded, so 
as to shorten the breath, after even a light meal of only a few 
cubic inches of victuals. In an hour or so the distention has all 

* See a comparison of the different gases of the alimentary canal as analyzed 
by Chevreul, Marchand, and Chevillot, in the author's work on " Digestion and 
its Derangements,'' book i, chap ix. 
35 



538 ERUCTATION AND VOMITING. 

gone, without making any sign of sudden departure, in a healthy 
person. But in an invalid body absorption is not so active. The 
gas normal to digestion is not taken up, and remains to disturb 
the patient by its continued presence. Should the oesophagus 
be in its natural state — that is to say, equally contracted through- 
out—the aerial contents of the stomach may be passed on through 
the pylorus, to produce, perhaps, the state of flatulence, which 
will be considered in a future lecture. Should that tube be re- 
laxed, then they break upward in eructations. 

So far, the bulk of air swallowed has been supposed to be in- 
creased only by heat and expansion. But in some cases it is 
further augmented by gases disengaged from the decomposing 
organic matters of the food. The occasional occurrence of the 
alcoholic fermentation in the digestive canal is proved by instances 
of vomiting, in which the matters ejected are seen actively under- 
going this chemical change. They are frothy and tumid, continu- 
ally swelling up and throwing off bubbles of carbonic acid, like 
yeasty beer. You have lately seen a man in Cambridge Ward 
in whom this condition of the ejecta was very conspicuous. Half 
a pint of vomit, left to stand, soon frothed up and ran over the 
edge of a vessel holding two quarts. You can easily imagine 
what a disturbance in the stomach all this frothing and boiling 
must make, and are not surprised at the rejection of such a tur- 
bulent guest. 

Fortunately the spread of alcoholic fermentation through the 
saccharine contents of the stomach is a rare occurrence. Its 
features are so marked, and the discomfort it causes is so great, 
that we should hear a great deal more about it were it common. 
The fact is, that even where it begins and gives rise to the dis- 
engagement perhaps of some carbonic acid, it is rapidly stopped 
by the conversion of the sugar into lactic acid, which is more 
congenial to the temperature of the body. So that the "acidity," 
which in a former lecture has been spoken about as an evil, is 
the guardian against a still more serious evil. 

It will be easily seen, from what has gone before, that the 
morbid states of which eructation is a phenomenon, naturally 
arrange themselves into three groups: (1) where there is simply 
a relaxed oesophagus ; (2) where there is an increased quantity 



ERUCTATION AND VOMITING. 539 

of atmospheric air swallowed; and (3) where foreign gases are 
formed from chemical decomposition. 

In the first may be included many cases of heartburn. The 
quantity of air brought up is small, but it seems to relieve the 
discomfort, probably by its stimulating the painful organ to con- 
tract — just as moving a cramped limb cures the spasm. It may 
be observed that these cases are made much worse by motion. I 
have been told by several patients that if they kept quiet after 
a meal they experienced scarce any inconvenience, while exer- 
cise at such a time invariably brought on eructations, hiccough, 
and heartburn. Sometimes the eructations are the most promi- 
nent symptom, and the heartburn is very slight. 

Under the same category may be classed cerebral diseases of 
a paralytic kind, where the partial loss of power in the oesophagus 
frequently causes eructation. 

In these instances the eructations usually occur very soon after 
meals, and have very little explosive character. 

In the second group come hysteria, epilepsy, and chorea. 
Watch a patient in an hysterical or epileptic fit, and you will 
see great gulps of air bolted down. In chorea, too, you may 
often detect by the eye or touch the involuntary spasm of the 
gullet, which gulps and swallows whether any solid matter is 
present or not. There is often, too, at other times, especially 
in hysteria, a spasm of the oesophagus, well known as globus 
hystericus. And less marked manifestations of the same phe- 
nomenon, uncomplained of by. the patient, or called simply 
"heartburn," occur constantly during the day, and fill the 
stomach with air. 

The excessive swallowing of air is often associated with a large 
or dilated stomach,* but I cannot satisfy myself whether it is 

* In 13 cases of dilated stomach which I have no iced — 

3 had gastric cancer (St. George's post-mortem book). 
2 had chronic ulcer, ditto. 

2 had dropsy and diseased liver, ditto. 

1 had ulcerated oesophagus and distorted ribs (St. Mary's post-mortem 

book). 
1 has a pendulous tnmor attached to the pylorus (alive). , 

3 have very fat omenta dragging down the stomach (alive). 
3 have albuminuria (alive). 



540 ERUCTATION AND VOMITING. 

cause or effect; I am inclined to think the latter, for the follow- 
ing reason : you find these dilated stomachs principally as the 
result of some mechanical pressure or drag on the organ from 
without, and therefore I do not know whether repletion from 
within alone would cause a permanent increase of area, more 
especially repletion with a substance so easily got rid of as air; 
while at the same time it is easy to imagine that a large, heavy 
empty stomach, dragging upon the cardia, should give rise to an 
instinctive gulping. 

In this class of cases the explosions of air occur at various 
times, but most markedly and most inconveniently immediately 
on swallowing food or drink. The air thrown up has little or no 
taste or smell. 

In the third group, where the gas is really generated in the 
alimentary canal, the eructations occur much later after eating — 
sometimes not till the time when, normally, the stomach ought 
to be empty; and if they do come close upon the meal, they con- 
tinue much longer, and do not give the apparent relief which is 
experienced in the other cases. 

The gases thus eructated are nauseous and fetid, sometimes 
with the odor of sulphuretted hydrogen. 

In these cases there is almost always mucous flux of the 
stomach, sometimes from anatomical changes in some part of 
the organ, sometimes without. The rationale appears to be, 
that organic matters in a state of decomposition remain adherent 
in the mucus, and act as ferments to the newly received food. 
Perhaps, too, the mucus itself may decompose. You know how 
quickly that takes place in urine, and how soon its decomposition 
is communicated to the rest of the fluid in or out of the body; 
and the same is likely enough to happen in the alimentary canal. 
The decomposition of the mucus is confirmed by the frequency 
with which different sorts of low organic growths (moulds) are 
found in it. The cryptogam sarcina ventriculi is the most dis- 
tinctly marked of these, and, though detected occasionally else- 
where, certainly finds its most congenial home in the stomach. 
In other places it has been found a floating wanderer in fluids, 
but in the mucous membrane of the stomach it may be seen fixed 



ERUCTATION AND VOMITING. 541 

and growing in the mucus. It is not often that an opportunity 
occurs of proving to the eye that such is the habitat of the sar- 
cina — we frequently find it vomited, but the patients seldom die 
during their illness, the complaint not being a fatal one. One 
such rare opportunity offered itself two years ago, in a girl of 
thirteen, who died in this hospital of enlarged heart. She had 
frequent attacks of mucous vomiting without sarcinse a few weeks 
before death, and at the autopsy we found the seemingly healthy 
great curvature of the stomach thickly clothed with a stringy 
mucus, very difficult to detach, in the outer layer of which a great 
quantity of sarcinse were imbedded. 

Being fixed thus in a permanent home, as shown by the above- 
quoted rare case, and rapidly replacing with new growths those 
which are wiped away by the food, the sarcinse is, unfortunately, 
by no means idle. A great number., perhaps all, of those crypto- 
gamous plants whose nature is to grow upon decomposing organic 
matter, have the property of promoting decomposition, so that 
they are not only the consequences, but the causes also of decay. 
It is found that the gutta-percha covering to electric-telegraph 
wires, when laid down near the roots of oaks, becomes rapidly 
rotten from the presence of a fungus peculiar to that tree. Put 
jam in a new cupboard, and it will keep much longer than in an 
old one where mould has previously grown. Economical house- 
wives have sometimes what they call a "vinegar-plant;" it is, as 
I show you here, a fungoid vegetable found in vinegar casks. If 
placed in sugar and water, it makes the whole undergo the ace- 
tous fermentation in two or three weeks, instead of the process 
occupying several months. The mould found in yeast, the torula 
cerevisiae, though not essential to alcoholic fermentation, cer- 
tainly augments the rapidity of its induction ; so that it is entirely 
in accordance with known physical laws if the presence of sarcinae, 
or of the yeast-plant, on the mucus of the stomach should bring 
on fermentation in the food before the obstructed absorbents 
have time to take it up. Both have been found in the contents 
of the stomach ejected; and it is shown by the case I quoted, 
that sarcinae at least may exist adherent to the mucus without 
being thrown up. Probably very often these plants are unseen 



542 ERUCTATION AND VOMITING. 

promoters of the rapid fermentation which takes place so mys- 
teriously in the stomach of invalids. 

Besides producing eructation, the fermenting of organic mat- 
ters in the stomach is almost always followed by vomiting; while, 
if it takes place in the bowels, the consequence is diarrhoea; two 
phenomena which will be considered shortly in their own place. 

The indications of treatment afforded by eructation are differ- 
ent in the three groups of cases in which it occurs. In the first, 
antacids are often sufficient for temporary relief. Four grains 
of rhubarb pill, with a grain of gallic acid, taken before dinner, 
will be found still more useful, for the tone thus given to the 
mucous membrane prevents the recurrence of the inconvenience. 
In more severe cases I have found a rhubarb draught with gallic 
acid, taken three times a day, a very efficient remedy. 

In the second group, where excess of air is swallowed, valerian 
and ammonia are very beneficial. Where there is nausea or 
vomiting, the valerianate of zinc may take their place ; but it is 
not so certain as the infusion or tincture of the herb. Where 
this fails, use strychnine, which you have seen in the wards to be 
the most powerful agent we have to steady such irregular nerv- 
ous action as hysteria, chorea, &c. 

In the third group, the great object must be to prevent de- 
composition. In the laboratory you find that no agent is so 
powerful in this respect as sulphurous acid ; and, accordingly, it 
is much used in various processes of the arts for the purpose. 
Sulphur is often burnt in casks to arrest the fermentation which 
is apt to be going on in the liquids soaked up by the cracks or 
porous parts of the wood, and the sulphurous acid vapors effect- 
ually do their duty. The Board of Health finds no disinfectant 
for fetid sewers so instantaneous in its action as Macdougal's, 
the chief ingredient in which is sulphite of lime. Meat may be 
preserved on the same principle, and keeps as. well as when 
salted or dried ; and you may test even on such a delicate 
substance as yelk of egg how fresh it keeps with any sulphite salt. 
The same effect is produced by taking as a medicine hyposul- 
phite of soda ; the fermentation of the contents of the stomach 
is arrested, and the evil effects of that fermentation prevented. 



ERUCTATION AND VOMITING. 543 

Another powerful arrester of chemical changes is charcoal. 
When soup has begun to turn sour in hot weather, clever cooks 
boil it again with a little bag of charcoal in it, and it becomes 
quite sweet. The same agent will prevent decomposition in the 
alimentary canal. I have used it, I must say, only in cases 
where decomposition occurs in the intestines, producing flatu- 
lence ; but I should not hesitate to employ it in gastric fer- 
mentation also, if hyposulphite of soda chanced to disagree or 
was not beneficial. 

Vomiting seems less than any of the phenomena previously 
discussed dependent upon the peculiar condition of the stomach, 
and more upon the idiosyncrasy of the individual. There are 
those who, whatever may be the matter with them, never vomit; 
while others do so on the slightest occasion. Even pleasant 
associations will, in some people, bring on this most unpleasant 
consequence : a patient of mine, a healthy young lady, is fre- 
quently seized with retching on entering a ball-room where she 
expects an agreeable evening ; while it never happens in going 
to a stupid party. On the other hand, I have had patients with 
cancer of the stomach, and others with various sorts of severe 
dyspepsia, who could take the most nauseating drugs without 
inconvenience. The mere fact of vomiting, therefore, affords 
in itself no clew to the local condition of the stomach. But the 
time of its occurrence, the circumstances which increase it, and 
the nature of the matters thrown up, may be most suggestive to 
the practitioner. 

Vomiting which occurs when the stomach is empty, or which, 
though it occurs at other times, is most frequent and distressing 
then, may be safely set down as arising not from any fault of 
the viscus itself. Such is the morning vomiting frequent in 
pregnant women, in cases of diseased heart, of abdominal tumor, 
and sometimes of pulmonary consumption. This is no doubt a 
reflex action of the vagus nerve excited by the irregular irrita- 
tion of some of its branches ; and on the same principle I can 
easily understand the more rare cases where vomiting has been 
caused by foreign bodies in the ear or nose, by tumors in the 
neck, &c. 



544 ERUCTATION AND VOMITING. 

When vomiting occurs with a replenished stomach, it may be 
considered as a general rule that the smaller the quantity of food 
that produces it, and the sooner it takes place after eating, the 
nearer to the mouth is the seat of injury. . Disease of the 
oesophagus causes rejection of the food before it has got down ; 
of the cardia, or smaller curvature, very soon after it has got 
down; and disease of the pylorus, or pancreas, or liver, after an 
interval sometimes of as much as several hours. 

When vomiting arises from congestion of the brain, as in 
apoplexy, drowning, concussion, or in dead drunkenness, it is 
increased by the horizontal posture; when it arises from deficient 
supply of blood, as in fainting, anaemia, and sea-sickness, that 
position relieves it. 

The contents of the vomit, which can afford practical sug- 
gestions to the practitioner, are the following : 

Mucus, if it is in large stringy masses, shows a generally dif- 
fused morbid condition of the stomach itself; if it is in small 
round lumps, it has most probably been secreted from the bronchi 
and swallowed. 

Blood, when it comes from an open vessel perforated by an 
ulcer, always is in considerable quantities, and contains black 
clots ; if it is mixed up with mucus, brown and shreddy, it 
denotes a high state of congestion of the gastric walls, with 
rupture of some small capillaries, or what is commonly called 
" exudation." 

Saliva, readily distinguished by its alkalinity, and the abund- 
ance of buccal epithelium contained in it ; when in large 
quantities, it denotes an irritable state of oesophagus and fauces; 
when it constitues the bulk of the vomit of pregnant women, 
you will often find associated with it a sort of salivation in the 
mouth. 

Fseces or fseculent smell. This is usually referred to a reversal 
of the peristaltic motion; but I do not think it necessary to 
resort to such a strained explanation. When we reflect that 
about twelve quarts of secretion are daily poured into the in- 
testines, it is easy to see that you have only to stop the onward 
peristaltic wave and absorption, for the ilia to get overfilled, 



ERUCTATION AND VOMITING. 545 

and for their contents to overflow upward into the stomach. 
There they naturally produce vomiting, just as they would if 
swallowed. Such a paralysis of muscles and absorbents takes 
place in peritonitis, as well as in mechanical obstruction of the 
ilia, and consequently in peritonitis you have sometimes fseculent 
vomiting. 

Fermenting matters in the vomit show the continuous reten- 
tion in the stomach of some remains of the food or of vegetable 
growths in a constant state of chemical change. There is there- 
fore present a quantity of adherent mucus capable of retaining 
them there. 

Acid matters in excessive amount may arise from a similar 
state of things ; but it seems as if simple torpidity of stomach, 
without the necessary presence of mucus, can occasion it. 

Pure unchanged food shows that the vomiting arises from the 
state of the nervous system, which is either locally irritable, from 
neighboring anatomical changes ; or secondarily, as in preg- 
nancy; or generally, as in hysteria. 

The remedial measures which I have found most useful in cases 
of vomiting are the following : 

Hydrocyanic acid, where it arises not from any fault of the 
stomach itself, but from the secondary condition of the nervous 
system, as in pregnancy, diseased heart, and abdominal tumor, 
in pulmonary consumption, in peritonitis. 

Carbonate of magnesia, in the vomiting accompanying gastric 
flux, with copious formation of acid. 

Opium, in acute vomiting from gastric ulcer, from malignant 
tumor, in fsecal vomiting from perforation, peritonitis, internal 
hernia — in short, wherever the vomiting is accompanied by much 
local pain. 

Chloroform, in the vomiting at the commencement of fevers. 
It maybe applied either on a cloth to the epigastrium, especially 
in choleraic vomiting, or taken by the mouth. 

Leeches. — Very often the vomiting in cases of gastric ulcer 
will not be appeased till some leeches have been applied to the 
epigastrium. 

Milk and lime-water, as a sole diet, will often alone stop 



546 ERUCTATION AND VOMITING. 

chronic vomiting. Complete rest and absence from excitement 
must accompany its use. 

Brandy ) in tea spoonful doses, is a favorite domestic remedy. 
It is suitable in acute cases for the nonce, and will often stop 
nervous vomiting from mental causes, but is obviously not 
adapted for chronic disease. 

Creasote. — This is an uncertain remedy, and I confess I cannot 
at all satisfy myself what cases it is suited to. The vomiting 
certainly seems checked by it sometimes, sometimes is aggra- 
vated, more commonly is uninfluenced. The cases where it has 
done good have appeared to me generally dependent on nervous 
causes. For example, it has been beneficial in hysterical 
vomiting. 

Valerianate of zinc I tried once in hysterical vomiting with 
good effect. But in these patients the most powerful remedy is 
the shower-bath. 

Ice is often most useful in acute vomiting in fevers, in chronic 
cases of gastric ulcer, and in all cases is an agreeable remedy in 
warm weather. 

The administration of food in cases of chronic vomiting is a 
matter of much importance. You must not let your patient be 
starved. Even when milk and lime-water does not check the 
vomiting, it is by far the best diet. In teaspoonfuls at a time, 
it can almost always be kept down. 

The risk of being starved to death from vomiting is not an 
hypothetical fear. A young woman came under my care at this 
hospital a few months ago who had been deserted by her lover. 
She had violent hysteria, and an utter inability to keep anything 
on her stomach for some days ; the pulse was failing, and the 
tongue getting dry and brown. An attempt was made to retain 
life by means of nutritive enemata, but in vain. At the post- 
mortem examination every organ was in a completely normal 
state, and the catamenia were still flowing from the uterus. She 
had died of starvation only. 

When sea-sickness goes to the extent of making a person se- 
riously ill, it is worth while to stop it or prevent it, as you can 
often do by a large dose of opium. But it is very far from being 



ERUCTATION AND VOMITING. 547 

worth while for healthy persons, or even invalids, in ordinary 
cases, to take this preventive ; for a small dose is useless, and the 
requisite large one makes the patient endure much more dis- 
comfort afterward than the sickness during the voyage would 
have caused. Chloroform does not arrest the nausea, but it cer- 
tainly does seem to control the violence of the straining. Effer- 
vescing stimulants are the most effective palliatives for healthy 
persons. In some rough rolling weather off the coast of Portugal 
I once tried on myself and several companions champagne and 
highly deviled biscuits with complete success. But the panacea 
is not always accessible ; the best imitation of it generally at 
hand is frothy bottled porter : if it does not in every case pre- 
vent the vomiting, yet the prostration afterward is avoided, and 
the ejecta are not so disagreeable as when they consist only of 
bile and acid mucus. Warmth is also very important : landsmen 
will often expose themselves as much as possible to the breeze, 
thinking that the freshening air will revive them and keep them 
well. This is a great mistake ; they should clothe themselves as 
warm as possible, put a flannel band or faja round the waist and 
abdomen, and above all things, keep dry and quiet, and when 
they feel miserable, go and sit with their backs to the funnel. 



LECTURE XLV. 

DIARRHOEA. 

Pathology of diarrhoea — Difference of it from mere frequency 
of evacuation — Division of diarrhoeas — Bilious — Watery — 
Muco-purulent — Bloody — Putrid — Their causes and indi- 
cations — Supplementary and reflex diarrhoea — Infantile — 
In fever— Ulceration of bowels — Mucous flux — Copious 
solid matter — Acid diarrhoea — Use of opium — Riding — 
Cautions about traveling — Flatus in ilia — Charcoal, $fc. 

[Extra course, St. Mary's, Summer Session, m 1857.) 

When the absorbing power of the intestines is defective, the 
consequence is an excess in the quantity of matters which pass 
through them ; that which ought to be taken up is carried along 
with the normal draught, and so constitutes a true diarrhoea. 

It is of great practical importance to distinguish this from the 
mere frequency of evacuation, which is quite consistent with a 
natural or even deficient amount of fceces. The number of mo- 
tions, or the number of times an inclination is felt to void them, 
is often increased when less than the average quantity may be 
passed in the twenty-four hours. This is of the nature of tenes- 
mus, and arises from an abnormal state, sometimes ulceration, 
sometimes piles, sometimes cancer of even colon or rectum ; 
whereas true diarrhoea as aforesaid, depends upon defective 
function of the ilia. 

The arrest of function, as declared by the prevailing contents 
of the stools, constitutes the best principle of division ; and 
according to it we may speak, without being misunderstood, of 
crapulous, bilious, serous, dysenteric diarrhoea, and cholera. 



DIARRHOEA. 549 

Crapulous diarrhoea is simply an excessive quantity of food 
taken, or arrested in its normal solution by suspension of the 
gastric function. It is called crapulous, because it is most usual 
after a debauch ; but in weakly persons it is not necessary that 
the intemperance should be absolute ; that which is moderation 
for others may be an excess in them. An examination of the 
feces exhibits a quantity of undigested food as the prominent 
feature, sometimes acid, sometimes fetid and fermenting, and 
rarely with enough bile mixed with it to prevent decomposition. 
Bilious diarrhoea is the next simplest form of the disorder. 
Bile, normally poured out by the liver to the extent of from three 
to four pints a day, if not concentrated by the intestinal absorp- 
tion, adds very largely to the quantity of excrement, where its 
presence is| declared by its well-known smell, and by a color 
exhibiting various shades of yellow, brown, and olive-green, 
according to its absorption of oxygen and mixture with fasces. 

This arrest of the absorbing powers of the intestines and con- 
sequent rejection of bile mixed at first with faeces, and when the 
bowels are emptied augmented by the exudation of water from 
their parietes, is what so often takes place temporarily from the 
impression of cold, from irritation of the alimentary canal by 
unwholesome food and from mental emotion. It is possible also 
that the qualities of the bile itself may be altered in some cases, 
or its quantity increased. It may be changed by medicines, as 
by calomel or by senna, and so rendered incapable of absorption, 
and be poured through the ilia without their being in fault. 
Congestion of the portal system, such as is especially frequent 
in Europeans resident in warm climates, causes the bile to be at 
one time deficient, and afterward to be poured out in excess. 
Irritation of the stomach and duodenum causes it to be retained 
in the liver and gall-bladder till it is unfit for absorption. In 
both these cases it, is rejected by the bowels, and constitutes 
bilious diarrhoea. 

You must be very careful to distinguish this symptoms from a 
different one, often confounded with it — viz., the presence of a 
bright grass-green matter in the stools. This is not bile at all, 
but in reality altered blood, and denotes congestive inflammation 



550 DIARRIKEA. > 

of the mucous membrane, a state requiring very opposite treat- 
ment from that proper for bilious diarrhoea. Your best aids to 
diagnosis are first, the smell : in real bilious stools the odor of 
the hepatic secretion can always be perceived, in spite of the 
faeces mixed with it ; and at the same time it always prevents 
putrescence, or even counteracts the incipient putrescence of the 
undigested aliments ; while in the grass-green stools the smell is 
not of bile, but more or less cadaverous or putrid. Secondly, 
the microscope exhibits in the mucus, which always is present in 
congestive inflammation, the usual globules of pus mixed with 
small shreds of fibrin and blood-globules. 

In serous or watery diarrhoea it is probable that there is an 
increased exhalation of aqueous fluid from the blood-vessels of 
the intestines, as well as an arrest of its absorption. In this 
form, when pure, if the faeces are retained by a voluntary effort, 
they may be concentrated nearly to their normal condition by 
the removal of the water, and thus a test afforded that their 
state depends mainly on the addition of this constituent; for 
that which can be so readily taken up again into the blood can- 
not be of a nature very foreign to it. Thus, for instance, if you 
take a saline purgative, you may feel several pints of fluid rolling 
about in the bowels ; but if you resist the inclination to stool, it 
goes off at last, and you void afterward little more than the 
ordinary amount of semi-solid faeces. It is not so in bilious or 
inflammatory diarrhoeas. 

Watery diarrhoea, when not arising from the antiosmotic action 
of neutral salts, indicates a congested state of the venous plexus 
of the alimentary canal, and a consequent morbid proneness to 
exhalation and deficiency in absorption. The vitality of the 
mucous membrane is deficient ; and if it is not restored, local 
death, exhibited in the form of ulcers and sloughs, must be the 
result. 

The exhalation, however, tends to become habitual, and so 
continues beyond the period of congestion, so that the whole 
maps of blood is relieved of its water, and in this way sometimes 
dropsical swellings may be reabsorbed and pass off through the 
bowels. 



DIARRHCEA. 551 

In dysenteric or muco-purulent diarrhoea, water is in excess, 
but the characteristic is the presence of mucus or pus mixed 
with it ; in which also there are, in cases seen early, shreds of 
fibrin, blood-globules, and flakes of the peculiar epithelium of 
the bowels. 

Should any of these products of inflammation be alone, sepa- 
rate and unmixed with faeces, then it is probable they come from 
the colon or rectum ; but if they are mixed up with a large 
quantity of watery fluid, and still more, if that watery fluid shows 
itself to be the serum of the blood by coagulating with heat, then 
there is little doubt of their source being the mucous membrane 
of the ilia, whose morbid condition it consequently indicates. 
The fluid in muco-purulent diarrhoea is always highly alkaline, 
and if it is examined with the microscope, crystals of ammonia- 
magnesian phosphate are found scattered through it. If allowed 
to stand, it separates into two distinct parts: the one serous, 
varying in color from complete whiteness and transparency 
through all the shades of yellow to deep brown, or where blood 
is present, to red and black, in which are the flakes of fibrin, 
the ammoniacal crystals, and floating globules ; the other sedi- 
mentary, consisting principally of gray, granular matter, the 
debris of food mixed with more or less of the coloring matter of 
the bile and half digested blood. 

The degree of serosity and the proportion of the products of 
inflammation in the first, show the extent to which inflammation 
has gone in the mucous membrane ; whiteness, bloodiness, putri- 
dity, alkalinity, being bad signs ; yellowness, opacity, the smell 
of bile, and the absence of putridity, being good. 

The second or sedimentary portion proves the condition of the 
general system rather than of the ilia in particular. If it is 
copious in proportion to the fluid, then the normal function of 
destructive assimilation is shown to be little interfered with ; if 
it is scanty, then we know this important process to be arrested, 
the effete morbid tissues are not being removed from the body, 
and a more grave state of affairs exists. The quantity of solid 
sedimentary matter is the best test you can have of an advance 
toward health, or departure therefrom, in all cases where there 
is this state of bowels. 



552 DIARRHCEA. - % 

The most common examples of muco-purulent diarrhoea are 
found among acute diseases, in low fever, in cholera, enteritis, 
and dysentery, especially in the teething dysentery of children. 
Among chronic diseases, ulceration of the bowels, whether a 
consequence of phthisis or low fever, is the most usual cause. 

Bloody diarrhoea, where the blood is in small streaks in the 
mucus, or slightly mixed with the serum, or mixed with the 
grass-green mucus above described, indicates a recent inflamma- 
tory state. When it is in clots, either black or fibrinous, with 
the globules partially washed away, it shows that a blood-vessel 
of notable size has been opened into, probably by ulceration. 
Should pus be mixed w T ith it, the diagnosis of ulceration is con- 
firmed. Black, semi-digested blood, precipitated by standing 
with the sediment of fluid stools, comes from high up in the 
ailmentary canal, as it indicates its exposure to the gastric juice. 
It not un frequently comes from the stomach itself. 

Putridity of the stools in diarrhoea always shows that there is 
an imperfect quantity of bile in them, one of the most clearly 
ascertained functions of the hepatic secretion being to prevent 
the chemical decomposition of albuminous matters. Putridity 
may arise from two sources — namely, the food taken, or the 
albuminous secretions into the alimentary canal. A close ex- 
amination of the stools will generally distinguish one from the 
other. If it is non-digested food which is decaying, then the 
solid constituents of the faeces are bulky, pale, containing large 
lumps of still paler substance visible to the naked eye. And if 
these are examined by the microscope, they will be found to 
consist of muscular fiber, fat, and other parts of victuals, often 
swarming with live infusoria and vibriones. This occurs from 
time to time in all cases of deranged digestion. If the fetor 
arises from the decomposed albumen of the exhaled serum, it will 
be observed to be exhaled from the more fluid part of the 
motions, which are like the "washings of macerated flesh, while 
the solid part is scanty and comparatively unaffected. This 
shows a much more serious state of the vital powers, and in severe 
complaints, such as low fever, is usually the harbinger of death. 
It is often joined to a peculiar mouse-like smell in the sweat. 



DIARRHCEA. 553 

In choleraic diarrhoea the whole mass of the blood is poisoned, 
and it is so altered in its physical qualities that very little of it 
remains capable of supporting life, or of absorbing the where- 
withal to support life either in the shape of food or medicine. 
The functions of the liver and kidneys are suspended for want of 
live blood, no bile appears in the stools or vomit, no urine in the 
bladder. 

For the purpose of understanding clearly the degree in which 
life is deficient in the different forms of diarrhoea, we may con- 
struct a table in which the first column is occupied by the several 
functions, the loss of one or more of which characterizes those 
different forms. It will be seen that the sign of minus may be 
placed against one after the other till the normal condition of all 
is finally lost, as an essential, not accidental, part of the disease. 



36 



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DIARRHCEA. 555 

In some instances of mucous flux and indigestion in the upper 
part of the alimentary canal, the stools are acid from time to 
time. There is nothing special in the pathology of this. It 
arises simply from so much acid being formed from the decom- 
position of food, that it cannot be neutralized by the alkaline 
juices. Sometimes the acidification takes place in the stomach, 
sometimes in the caecum, during the delay of the decomposing 
aliments there. In the latter case considerable pain is often 
experienced in the right iliac region, and in the course of the 
colon just before the evacuations. 

In all forms of diarrhoea from affections of the small intestines 
the evil is twofold : first, the aliment, which ought to contribute 
to the support of the system, is hurried through the abdomen, 
and so the supplies are cut off; and secondly, destruction is 
carried on at an increased rate by exhalation from the mucous 
membrane of the bowels. The stick is being cut away at both 
ends, and hence there is nothing which produces such rapid 
emaciation. Where so-called " diarrhoea" is reported to you as 
lasting for any length of time without emaciation, always let 
your suspicions of the correctness of the nomenclature be roused, 
and observe carefully whether the quantity of excrement be really 
in excess, or whether the ailment have not rather the nature of 
tenesmus, and arise from the colon or rectum. You will gen- 
erally find such to be the fact, and must vary your treatment 
accordingly. 

Sometimes diarrhoea seems to be the transference of a tend- 
ency to exudation of serum from another tissue to the aliment- 
ary canal. Such is that which sometimes comes on of its own 
accord or may be artificially induced in ascites, and which cer- 
tainly diminishes the abdominal effusion. Such is the diarrhoea 
of uraemia, which, however, does not usually relieve anarsarca, 
but rather increases it from the weakening of the blood which 
follows. Hence it is a very bad, almost a fatal symptom in the 
latter disease. 

The most important indication of treatment is connected with 
the diet. It must be such as does not require a perfect state of 
the digestive organs for its absorption, while at the same time it 



556 DIARRHOEA. •» 

is nutritive to the patient. The best of all is milk and lime- 
water. In feverish cases it may be iced, and soda-water may be 
occasionally substituted for the lime. Keeping a person solely 
on this diet is often sufficient alone to cure all sorts of diarrhoea 
not dependent on a permanent chronic cause ; and even where 
there is such a cause for it, very great temporary benefit is 
derived, which forms a better starting-point for medicinal treat- 
ment than the previous state. 

In a temporary diarrhoea without other disease, the loss of the 
normal supply to the body is not of so much consequence ; a short 
starvation perhaps does good to a person otherwise healthy. 
But in severe acute disease, or in long-continued chronic diar- 
rhoea, this is an important consideration, and care must be taken 
to allow for it. Since food in the usual quantities at once can- 
not be borne, and is rejected undigested, give it very frequently 
and in small portions. The alkaline milk diet I have just recom- 
mended allows this to be done most conveniently. A jug of the 
liquid may be kept close at hand, and sipped from time to time, 
so that as much nutriment may be taken in the twenty-four hours 
as would be done by a healthy person without the alimentary 
canal ever being overloaded. 

When there are lumps of fseculent matter in the stools, and a 
smell like that of normal excrement, give purgatives. Until you 
get rid of these remains of previous constipation, you will be sure 
to have a relapse of diarrhoea, though your medicines may check 
it for a time. When there is no normal smell present, I have 
never found purgatives beneficial. This is a better rule than the 
routine practice of always commencing the treatment with a pur- 
gative — a plan which I have known very injurious in cases of 
chronic diarrhoea. 

Where the products of acute inflammation are found mixed in 
the stools, such as white and opaque mucus, flakes of fibrin, 
epithelium, blood-streaked mucus, bright-green matter, &c, as 
above described, leeches, fomentations, warm hip-baths, and 
poultices to the abdomen are the appropriate treatment, and 
should not be delayed. In the case of babies, the whole abdomen 
and loins may be fastened up in a large circumambient poultice, 



DIARRHOEA. 557 

which they cannot wriggle away from, a leech put on near the 
navel, and the bite allowed to bleed for a little time. The drugs 
I have most trust in are calomel, ipecacuanha, and carbonate of 
soda. Of the first and second equal quantities, and a double 
quantity of the third may be made into powders, of which from 
four to six grains, according to the child's age, may be given 
every three hours. This is a traditionary powder, but it is right 
to say that I have in a good many instances lately left out the 
calomel, and the case has done just as well if not better with- 
out it. 

Be very careful in infants to look to the teeth. The state of 
the bowels may very likely be dependent on reflex irritation from 
the dental nerves. Lancing the gums will sometimes stop a most 
violent diarrhoea where the stools show evident proofs of the in- 
flammatory condition of the ilia. The action of the lancing is 
probably much the same as that of leeches, viz., a relief to the 
congestion of the mucous membrane. Upon the development of 
the teeth themselves it can hardly be supposed to have any influ- 
ence, but that it alleviates toothache any adult can experience 
on himself, though it is difficult to get an account of the action 
of the remedy from his little patients. 

In teething infants opium is of striking utility. I begin with 
half a grain of Dover's powder every three hours, increasing the 
dose by half a grain every three hours till a decided excess of 
sleepiness is produced by it. 

But there is no doubt that the most important cure in infantile 
diarrhoea is change of diet. Bringing up by hand or an unwhole- 
some state of the breast-milk are generally at the bottom of the 
ailment. No remedy is equal to a healthy wet-nurse, or, where 
circumstances forbid that, as near an imitation as can be made 
of human milk by that of animals. The old fashioned donkey's, 
or the cow's diluted and slightly sweetened. 

In low fever the presence of diarrhoea indicates to many prac- 
titioners the employment of mercury in the form of mercury with 
chalk. The effect of this drug is the increase of solid sedimentary 
matter in the stools; in other words, a restoration of the de- 
structive assimilation going on in the body. The motions are 
diminished in number and in fluidity, but not in actual quantity. 



558 DIARRHOEA.'* 

Thus the tissues devitalized by the typhoid poison are removed, 
and can be replaced by new nutriment. This increase of solid 
matter is taken as an evidence and test of benefit accruing from 
the use of mercury, and as a prognosis of good. But I confess 
I prefer the chalk without the mercury in the shape of mistura 
cretae or the employment of mineral acids. 

Where in the absence of fever blood is passed by the bowels, 
the two most powerful means of checking it I have found to be 
turpentine and acetate of lead, especially the latter. Its direct 
influence as a poison on the bowels would have led to an expect- 
ation of this. If the haemorrhage has gone on for some time, I 
am inclined to think it must be sometimes due to a clot distend- 
ing the bowel, and preventing it contracting upon the bleeding 
spot, for certainly a dose of castor oil, in the results of whose 
action a quantity of pale clots were exhibited, has several times 
in my experience stopped haemorrhage from the bowels. 

The long continuance of diarrhoea from ulceration of the ilia 
must starve the patient. It tends also to prolong itself; for the 
weaker the system is the more irritable are the sore places, and 
the less can the morbid actions they set up be resisted. It is 
right, therefore, to use direct means for arresting the diarrhoea. 
The best are such as blunt the sensibility of the ulcerated spots. 
The milk-and-lime-water diet should be used first, then chalk and 
opium, which appear to act on the sore mucous membrane just 
as they do on a raw blistered surface of skin. If these fail, sul- 
phate of copper should be used in doses increased from a quarter 
of a grain up to two grains. If no good accrues after this, I 
suspect an error has been made in the diagnosis. 

Where there is a simple flux of transparent mucus without 
fever, pain, or pressure, or any fibrin or blood in the motions, 
the vegetable astringents, such as logwood, bark, kino, and tan- 
nin, are often of great use. In such cases, too, I have prescribed 
iron with seeming benefit. I must, however, say that I feel 
doubtful in the great majority of instances whether this form of 
flux is not rather due to the colon than to the small intestines. 

Where the solid matter is copious, pale, and fetid, consisting 
mainly of undigested food, inspissated bile may be given with 
benefit; the stools become darker, less fetid, and less frequent 



DIARRHCEA. 559 

under its employment. This is particularly the case in children 
whose mesenteric glands are diseased. I am hopeful, too, that 
pepsine will prove a still more efficient remedy in the same cases, 
as it certainly diminishes the fetor of the motions in the best 
way; namely, by promoting the normal solution of the food. 

Acid diarrhoea indicates the free employment of chalk. 

The use of opiates in diarrhoea must never be made a matter 
of routine. As a general rule, I have found them beneficial 
without consequent harm, in cases where there was tenesmus 
and frequent stools; but where the faeces are bulky and copious 
they appear to impede the natural secretion. Where the stools 
also are putrid, caution is required in their use. In the diarrhoea 
which so often accompanies and proves fatal in uraemia, they 
check, indeed, the debilitating flux, but they are apt to bring on 
coma. 

In some cases of diarrhoea from chronic mucous flux of the 
intestines, without ulceration or acute inflammation, I have found 
horse exercise serviceable. I suppose it is the gentle agitation 
of the abdomen, combined with the air and amusement, that 
proves of use. 

In recommending the recreation of traveling to invalids sub- 
ject to diarrhoea, you must be very careful of the route you 
select. The epidemic influence of cholera which has overspread 
Europe during the present generation, visiting almost every 
square mile of its surface several times during the last few years, 
has, in many places, left behind it a chronic endemic poison. 
The natives are, indeed, insensible to it, but few strangers escape 
becoming affected more or less, according to their idiosyncrasies. 
Strong persons find it only an inconvenience, but an invalid is 
put in some danger, and certainly loses all the advantage of the 
tour. This is especially the case in the mountainous districts of 
the south of France, the Pyrenees, and Dauphiny, and in the 
volcanic regions bordering the Rhine, the Eifel and Moselle 
country, as well as those in the center of France, the ancient 
province of Auvergne. All these places are attractive from 
their picturesque beauties, and therefore it is necessary that you 
should be warned of this evil attendant upon choosing them as 
the scene of a tour. You will see sometimes the whole of the 



560 DIARRHOEA. * 

strangers at a table d'hote obliged to leave the room at once, 
and cause one another no slight inconvenience by tending all 
together in the same direction; and in the Pyrenees I have seen 
powders of chalk and opium packed up as the regular concomi- 
tants of a day's walk. It must not be supposed that this is the 
result of the foreign modes of cooking. I have known English 
biscuits and porter, and boiled eggs, adopted as a diet without 
relief, though of course nothing foreign could have got into them. 
I believe the cause to be as I ha.ve represented it; namely, a 
poison left endemic since the passage of cholera through the 
country, but to which the natives have become acclimatized. 
That it is of late years only that this diarrhoea has been prevalent 
is shown both by local report and the omission of all mention of 
it from the well-known work on "Climate," by Sir James Clark. 

One source from which strangers contract this diarrhoea is an 
evil capable of, and rightly demanding, an amendment : I refer 
to the filthy privies in continental inns. A gentleman, eminent 
in his profession and of good judgment, told me that, during a 
Pyrenean tour lately, he entirely escaped the diarrhoea which 
everybody else without exception suffered from, by adhering to 
a strict rule of never entering one of these disgusting holes, but 
worshiping Cloacina under the pure light of the stars. Invalids 
and ladies cannot so well manage this unless they are rich enough 
to travel with carriages and servants and peripatetic water- 
closets. With few exceptions, I think patients with diarrhoea 
had better stay at home. 

Flatus in the small intestines is one of the most trouble- 
some forms of wind. If it escape into the stomach, which is for- 
tunately rare, the taste and smell are peculiarly nauseous ; while 
it seems to have considerable difficulty in passing the ilio-cascal 
valve. Hence it rolls about in the abdomen from the changes 
in position which the motion outward of the alimentary masses 
involve, and causes the well-known and distressing "borbo- 
rygmi," till it can get absorbed. The abdomen will often be dis- 
tended for several days with it, without its being able to escape. 

The persons most liable to this troublesome affection are fat 
anaemic and hysterical women ; it follows also the small and con- 
tracted liver of spirit-drinkers, and sometimes is very annoying 



DIARRHCEA. 561 

in cases of dilated heart. Some persons, in apparent health, 
are habitually much troubled with it. I am inclined to attribute 
it under these circumstances to a naturally sluggish portal circu- 
lation, which does not so quickly absorb the contained air as a 
freer current through the blood-vessels would enable it to do. 

Flatus in the intestines is troublesome during the day, from 
the tumidity of the abdomen, and noise on motion, and pain in 
the side ; but when it comes at night it causes still more incon- 
venience by preventing sleep. I cannot explain why this is ; 
there is not enough pain or discomfort to account for it, yet a 
complete wakefulness and apparent want of desire for sleep com- 
monly prevails. It is to be remarked, also, that it is in most 
instances made worse by opium. Sometimes the patient will go 
to sleep easily and naturally on first lying down, and will then 
wake up in an hour or two, finding his abdomen tumid and un- 
comfortable, and will remain entirely without rest for the re- 
mainder of the night ; or if he drop off for a few minutes into 
unconsciousness, it seems rather to aggravate than relieve the 
feverish restlessness, and to cause headache. 

The most serviceable remedy is finely-powdered animal char- 
coal, in doses of from ten to twenty grains, and of the aloes-and- 
myrrh pill just enough nightly not to act as a purgative. The 
air seems to be absorbed, and the peristaltic motions quickened, 
by this treatment. Should that not be effectual, you can employ 
strychnine in small doses in the pill. 

It is scarce needful to say that indigestible articles of diet 
must be shunned, if the patient would avoid a recurrence of the 
complaint ; and it stands to reason that cold sponging and bath- 
ing, sea-water — and in short all hygienic remedies which improve 
the general health — will conveniently accompany the treatment. 

I have known two cases of habitual looseness of bowels cured 
by marriage. In one of these the change was sudden and im- 
mediate : a gentleman from boyhood to the age of thirty-five 
had been used to have the bowels opened at least five times a 
day ; a week after his wedding the number of evacuations was 
reduced to two, and before the year was out to one daily. I 
presume it is requisite for the marriage to be a happy one — a 
Xantippe would not, probably, lead to the same soothing result. 



LECTUEE XLVT. 

COSTIVENESS AND CONSTIPATION. 

The difference between costiveness and constipation — Costiveness 
dependent on retained excernible matter — What diseases 
it accompanies — Cause, defective vitality — Effect on the 
nervous system and mind of retained excernible matter — 
Indications of treatment — Inconveniences of purgatives — 
Sort of purgatives to be adopted — Dietary — Water — Water- 
ing places — Cautions in use of them — Hydropathy — Consti- 
pation — Causes — Irritating food — Unabsorbable food — 
Remedies — Flatulence in colon — Distinguished from that 
in ilia — Remedies — Slight cases difficult to relieve. 

[Extra Course, St. Mary's, Summer Session, 1857.) 

The opposite states to diarrhoea are "costiveness" and "con- 
stipation." In the former the quantity of faeces is too small; 
in the second, the expulsive power is in default. 

Costiveness arises from deficient excretion in the alimentary 
canal. What proportion of the matters that ought to be thus 
got rid of comes from the liver we have not yet the means of 
knowing, but the main point, that they are derived from portal 
blood, we are justified in asserting ; so that the solution of the 
former question is of the less importance. 

That a great deal of the color of faeces is due to bile is familiar 
to us from the phenomena attendant on obstructed gall-ducts. 
But even when there is complete occlusion of the communication 
between the liver and intestines, the faeces by no means consist 
entirely of undigested food ; there is in them a great proportion 



COSTIVENESS AND CONSTIPATION. 563 

of a yellowish-gray granular matter which appears also in the 
healthy state, and still makes up the bulk of the solid excreta. 

In deficiency, therefore, of the excretive powers of the intes- 
tines generally (yulgo "costiveness" or "biliousness"), there is 
a different substance retained than is the case when local lesion 
of the liver or gall-bladder obstructs the passage of bile. There 
is a partial retention of the whole matters destined for depura- 
tion from these quarters, instead of a complete retention of one 
constituent. 

Hence there is not, as happens in mechanical retention of the 
bile, the well-known stain of jaundice communicated to the blood 
and skin, nor are the stools clay colored. But there is a dingi- 
ness and darkness of complexion, and the stools are scanty. The 
skin gets greasy and opaque, the countenance sometimes puffy 
and bloated, sometimes thin and pale, the lower eyelid especially 
sallow and discolored. The sebaceous follicles on the alse nasi 
are stopped up with black matter. 

There is seldom any decided emaciation, nor is there always 
even loss of muscular power ; but still there is great sluggishness 
of body and apathy of mind, and often a miserable want of de- 
cision and energy. Digestion is accompanied by a good deal 
of discomfort and flatulence, but rarely by actual pain, and the 
distress does not begin till several hours after eating, so as to be 
with difficulty referred to any particular meal. 

In the least complicated cases of checked intestinal secretion 
the stools are dark, hard, and dry ; but their appearance may be 
varied by several circumstances. Sometimes there is an aug- 
mented secretion of mucus, and then they are intimately mixed 
up with it, forming a black, slimy, almost gelatinous mass. 
Sometimes, from the appetite not suffering, the patients will eat 
largely, and then there appears irregularly from time to time a 
quantity of fetid, semi-digested food, constituting a sort of diar- 
rhoea accompanied with pain and colic. And this diarrhoea will 
often be the occasion of your patient's first coming to you, so 
that you might be deceived into a false impression of the case. 

The congestion of the portal vessels in the upper part of the 
alimentary canal is often followed by the same state in the lower, 
and thus piles are formed, which add much to the general distress. 



564 COSTIVENESS AND CONSTIPATION. 

Costiveness is a common accompaniment of anaemia, chlorosis, 
debility in males and females, or diseased hearts especially where 
the muscle is dilated rather than hypertrophied, of contracted 
liver, and in short, of anything which makes the abdominal cir- 
culation sluggish. Sometimes it is found in cases of pulmonary 
tuberculosis, but hardly ever before middle age. All those pul- 
monary cases in which I have seen it last long enough to be a 
marked feature have been examples of senile phthisis. It is often 
the first and most characteristic phenomenon of that change of 
system which takes place in females after the cessation of the 
catamenia. The stools get gradually more and more scanty as 
the uterine secretion also diminishes, the pulse grows feebler, 
the feet and hands more liable to get cold. There is evidently 
lessened vitality throughout the whole body. 

No persons more frequently suffer from costiveness and its 
attendant " biliousness" (as the general appearance of the skin 
is named) than old Indians. Their sedentary routine life and 
high feeding are partly chargeable with their liability. But in 
addition to this, the endemic diseases of the country are often the 
exciting cause. I have traced the commencement of a costive 
habit of body several times distinctly to an attack of dj^senteric 
fever brought on by malaria. So that the Anglo-Indian who 
suffers in this way must not be always accused of previous 
excess. 

The natural end of this state of things, if left unchecked, is 
gradual progress from bad to worse. The decrease of destructive 
assimilation loads the tissues with effete matter, useless for the 
purposes of life, and a constant source of general discomfort. 
This impedes the constructive assimilation of food as well — 
growth is arrested, the blood is not renewed, and hence progres- 
sive anaemia, weakness, want of nervous and muscular power, 
and probably in the end the degeneration of one or more of the 
viscera, and death from that cause. 

One very striking attendant on the loss of destructive assimi- 
lation is the depression of spirits ; melancholy is so named from 
the dark, scanty stools which were observed by the Greeks to be 
associated with it. It appears to me to be a universal rule in 



COSTIVENESS AND CONSTIPATION. 565 

disease that the general discomfort is proportioned to the arrest 
of this vital process, and I am inclined to attribute it almost 
entirely to the influence on the nerves of general sensation of 
effete matter which is retained. In all maladies, both acute and 
chronic, you may observe the truth of this law. Mark, for 
instance, the ushering in of a fever: the malaise is excessive; 
there are pains in the back, in the head and the limbs, or, in 
milder cases, a sense of what the patients graphically call "all 
overishness;" but when they get worse, and destruction begins, 
the effete matter passing off as urea and increasing the specific 
gravity of the urine, — then no aggravation of local symptoms, 
however much it may alarm their physician, and make his prog- 
nosis graver, prevents the general feeling of relief. Or watch 
a case of consumption ; the deposit of the tubercle may be in- 
significant, and is at all events in its first stage ; yet the patient 
is despairing of recovery. Why ? Because the skin is sluggish, 
the bowels costive, the urine of low specific gravity; because, in 
short, there is evidence of the retention of effete matter in the 
system. But let this patient's tubercles soften, let there be night 
sweats, copious expectoration, diarrhoea — everything that pro- 
phesies ill — and who so full of hope as the poor blind sufferer ? 
Morbid states where destruction is in excess are the most fatal, 
but those where retention preponderates are invariably the most 
distressing. 

Costiveness must be regarded as a disorder of the whole system, 
and not of the intestinal canal alone. The only effectual remedies 
are those that are advised under that conviction. 

The objects of treatment must be : first, to relieve the body of 
the immediate presence of effete matter ; and, secondly, to pre- 
vent artificially its reaccumulation till such time as a complete 
renewal of the tissues has taken place. Then the body ought to 
be able to take care of itself, and a cure may be said to have 
been performed. The attention to local disorders, arising from 
the successful study of morbid anatomy, has too much made us 
forget this main object of all medical advice — the replacement 
of morbid tissue by healthy. " Renew my age," was the chief 
earthly blessing prayed for by the inspired prophet ; and physi- 



566 COSTIVENESS AND CONSTIPATION. 

ology teaches us it should be the motto of the rational physician ; 
for if he omits to rebuild the healthy, his care for the destruction 
of the unhealthy is all thrown away. 

Purgatives, then, may very fairly begin the treatment ; for 
the immediate relief they give to the feelings of discomfort is 
great. But let not that relief be set down to the mere " clearing 
out of the bowels ;" it is the cleansing of the blood which is the 
real object of the remedy, and the real cause of the relief. An 
inspection of what comes away shows you it has been newly 
formed ; it is fresh bile and other natural constituents of recent 
faeces ; not of those which have rested long in the canal. 

Nothing is easier than thus with a vigorous blue-pill and black 
draught to drive away, as with a charm, the patient's discomforts ; 
and he is ready enough to cry out that no more medicine is 
wanted. But what is the consequence of leaving off treatment ? 
The renewal of the blood and tissues not having had time to re- 
gain its original activity — there not being enough new-made 
blood to carry on vigorous life — the effete materials again col- 
lect, and the disease takes a fresh starting-point. Again and 
again the coarse expedient is called for, and at last fails to effect 
its object of giving relief. 

To avoid this evil consequence, it is best to give no quickly- 
acting complete purgatives which directly deplete the abdominal 
plethora by serous exudation, but rather such as cause a gradual 
increase in the solid matter of the stools. Aloes and rhubarb 
are the best of these ; and I find it also beneficial to combine 
with the. drug resins which act as a tonic to the surface of the 
mucous membrane, and prevent the exudation of serum and 
mucus. Four grains of aloes and-myrrh pill, every night, will 
in a week produce all the good effect of strong purgation ; and 
it will produce the good permanently instead of merely for a 
time. 

All accessory food that has the property of arresting destruc- 
tion must be left off. Wine, beer, tea, and coffee must, on this 
account, be excluded from the dietary ; and milk, cocoa, whey, 
soda-water, Seltzer-water, &c. substituted for them. 

Perhaps it is on account of their temporary arrest of destruc- 



COSTIVENESS AND CONSTIPATION. 567 

live assimilation, that general tonics, such as cinchona and 
quinine, rarely agree well in those cases. I find it better to give 
pure bitters, such as oak-bark, quassia, and gentian, which seem 
to act chiefly on the mucous membrane. Their use is to increase 
the appetite ; and, when the object is attained, I leave them off; 
or, if it is attained without them, I do not begin. 

Water is a very accessible remedy, and certainly a very rational 
one, when the destructive assimilation is deficient. The conclu- 
sive experiments of Dr. Bocker and of Dr. Falck,* show the 
increase of all interstitial metamorphosis by this agent to be in 
close proportion to the quantity taken within certain bounds ; 
and all who have heard or read of the agreeable sensation ex- 
perienced by patients during the water cure cannot doubt its 
power of removing morbid accumulations of effete matter in the 
tissues. In this lies its strength ; for, as Dr. Bocker observed, 
a the demand for new tissue, as expressed in the sensation of 
hunger, keeps pace exactly with the extent of the metamor- 
phosis." And if this demand is rightly supplied, the result must 
be a complete renewal of the body. 

The testimony of experience to the use of water as a remedial 
agent is shown in the patronage bestowed from the earliest 
times upon numerous springs whose saline constituents are even 
less abundant than those of ordinary drinking-water. Pfeffers, 
historically famous for freeing Martin Luther of his demon- 
haunted hypochondriasis, is still the resort of the invalid. It is 
situated in a most gloomy hole ; and the copious hot stream that 
boils out of the rock is almost chemically pure. So really the 
pure nymph of the fountain, innocent of salt, should have the 
whole credit. The same may be said of the well-known Gastein 
and Wildbad, the crowded Baden, imperial Plombieres, of the 
French Aix, and our own long-frequented Buxton ; for, practi- 
cally speaking, the influence of the saline particles they contain 
must be reckoned for nothing. It is certainly nothing compared 
with the effects of moderate doses of water in Dr. Bocker's ex- 
periments. 

* See " Digestion and its Derangements," p. 217 : and " Zeitschrift der K. K. 
Gesellscbaft der Aertze zu Wien," April, 1854; and Vierordt's " Archiv.," i, p. 



568 COSTIVENESS AND CONSTIPATION. 

As physiologists we cannot be surprised at the benefit derived 
from the simple expedient of drinking water beyond the demands 
of thirst, in all diseases of arrested metamorphosis. Taken several 
times a day between meals it is a most efficient remedy. Warm 
hip-baths are also of great use, and can be borne even from the 
first by those reduced to extreme anaemia and lifelessness. After- 
ward, the cold sponge-bath, preceded and followed by friction 
to the skin, is a most active promoter of life in the skin and 
capillaries. The raising the specific gravity of the water by the 
addition of salt prevents the chill which fresh water is apt to 
impart. So that even persons with cold hands and feet, and very 
great sluggishness of circulation, can bear to be sponged with 
brine. 

Alkalies and neutral salts have the same action on the moult- 
ing of effete tissues that water has. Hence the repute of many 
really strong mineral wells. But care is needed lest the same 
result should follow their use which is threatened by the un- 
guarded use of purgatives. In cases where there is pure arrest 
of metamorphosis, without organic change in any of the viscera, 
I find that the weaker the spring the better it is for the patient. 
Where, however, any organ is chronically degenerated, general 
consent seems to sanction even such waters as Vichy and Sel- 
ters, with their large amount of alkaline constituents. 

While pulling down an old house, remember to be building up 
the new. Let full supplies of albuminous material be continu- 
ously kept up in such form as the absorbents love. Let milk, 
mutton, and bread be the staple diet, with the smallest quantity 
of anything else that human gluttony will submit to. If your 
patient be one of strong mind, the best and bravest thing is for 
him to carry out your advice himself. He will then have gained 
a victory, not only over the flesh, but over the spirit. But if he 
is no Epictetus, and cannot attain to the dignity of being his own 
jailor, do not be afraid of sending him to an hydropathic hotel. 
You will generally find the proprietors of these establishments 
willing to carry out your directions, and the situations of most 
of them are judiciously chosen for the advantages of air and 
amusement. The principle of scientific hydropathy, the renewal 



COSTIVENESS AND CONSTIPATION. 569 

of the body by water and food, the increase of growth secondary 
to the increase of moulting, is no quackery. It is not an under- 
hand mode of doing nothing, but a bond fide use of a powerful 
agent. 

I know that medical men are afraid that in sending patients 
to water-cure establishments they may be aiding and abetting 
the pretensions which ignorant proprietors have put forth, of 
their treatment being a panacea for all ailments. In my opinion 
a contrary effect would follow ; for the very fact of regular prac- 
titioners adopting the reagent as remedial, will show that science 
ranks it as a physical power; that, consequently, it will do as 
much harm in some cases as it does good in others; in fact that, 
like all medicines, it will kill as well as cure. This is indeed 
the truth, and patients are as unwise to prescribe it for them- 
selves, or on the advice of a hotel-keeper, as they would be to 
take arsenic or strychnine, or to cut their legs off, on the same 
grounds. 

Constipation is often added to costiveness, but is not neces- 
sarily connected with it. In it the faeces collect in some part of 
the abdominal canal, and give proof of that collection by being 
occasionally passed in considerable quantities at a time. In the 
stools there are portions more dried and concentrated than the 
general mass — scybala of various sizes and shapes, dark brown 
or black, and usually with less smell than ordinary faeces. 

The most obvious cause of constipation is mechanical obstruc- 
tion, the nature of which, under various forms, has been fully 
explained to you in the ordinary courses of medical and surgical 
lectures. 

Simple atony of the colon presents a much more frequent and 
more curable cause. And not rarely a mucous flux of the 
stomach or intestines will originate constipation by enveloping 
the faeces in a slimy coat, and preventing their being moved on 
by the muscular contractions of the gut. Atony of the colon 
arises primarily in those who lead a sedentary life, and have 
that pale look which characterizes weak muscular fiber. It is 
more frequent in the old than in the young; indeed, a diminished 
propulsive force in the large intestines may be considered as a 
. 37 



570 COSTIVENESS AND CONSTIPATION. 

normal consequence of advanced age. It is very usual in con- 
valescence after acute fevers and other debilitating diseases. 
Neglect of the natural call to evacuate the bowels, and the re- 
tention of wind in the colon, also produces this sort of torpidity 
by too long-continued dilatation. Hysteria and nervousness in 
either females or males often spasmodically contract the rectum, 
so that the faeces are kept unnaturally back, and thus the same 
state of things arises as from neglected evacuation. The irrita- 
tion of piles occasions a similar result. 

Where there is a disposition in the colon to be atonic, this 
disposition is much aggravated, and sometimes first made evi- 
dent, by some kinds of diet more than others. It is a mistake 
to suppose that indigestible articles of food " irritate," as it is 
called, the bowels; that is, pass on quicker than more soluble 
substances. The contrary is the case; and, as a general rule, 
the gradual and regular transmission of the mass is in direct 
proportion to the completeness of its digestion. No sort of food 
is so apt to be followed by constipation in atonic persons as that 
which contains a large amount of matter incapable of being 
acted upon by the digestive juices, such as the husks and stones 
of fruit, stringy half-cooked vegetables, in which, besides cellu- 
lose, there is the equally impracticable body, unbroken starch. 
All substances capable of being squeezed into an impenetrable 
mass, such as pun pastry and new bread, come under the same 
class of insolubles; and perhaps, too, gum and gelatine are liable 
to the same imputation. 

The most successful practice in simple constipation is the free 
use of cold water enemata, and a long-continued course of small 
doses of strychnine. When there are no piles, the latter medi- 
cine may be advantageously combined with aloes. This treat- 
ment does not forbid the administration of tonics, or whatever 
else may be needful to relieve the disease in which constipation 
occurs; which disease of course requires to be removed before 
the local symptom will be free from risk of relapse. It is scarcely 
necessary to say that no treatment will avail if the bad habits 
which have induced the constipation are persisted in. 

Where the constipation arises from mechanical impediments 



COSTIVENESS AND CONSTIPATION. 571 

to the movements of the bowels upon one another, such as adhe- 
sions of the peritoneum, contraction from old ulcers, from past 
inflammation, or compression of the area of the gut, such as arises 
from tumors, from retroversion of the uterus, and the like, a more 
soothing treatment should be adopted. Then the enemata should 
be warm, and have an ounce of olive oil added to them. If there 
be localized pain, dissolve some opium in the oil, and put some 
leeches to the spot outside corresponding to the seat of pain. 
Hot fomentations and poultices containing fresh laurel leaves 
also give great relief. 

The depending position of the caecum makes it the commonest 
seat of fecal collections; and if you find it difficult to fix on any 
other spot, it is wise to take it for granted that this is the failing 
one, and direct your local application accordingly. 

Do not be satisfied with the one or two very copious stools 
which will follow your efforts; the treatment must be persevered 
in until the bowel has recovered its tone, or there will be great 
risk of relapse. 

Flatulence in the Colon may be distinguished from that in 
the small intestines by the percussion, by the absence of borbo- 
rygmi, and by its frequently passing freely out per anum. It is 
a very usual accompaniment of constipation, and in that case has 
the same pathology, being to the air what the other is to the solid 
faeces. If the flatulence is a very marked symptom, a carmina- 
tive, such as extract of rue, or a few drops of ether, may be 
added to the enema. 

Milder cases of colonic flatulence, without marked constipa- 
tion, are often found more difficult of cure than the severer. 
The reason is simply that which applies to all of the less incon- 
venient forms of disease — namely, that patients will not take 
the trouble to be well unless under strong compulsion. 



LECTURE XLVII. 

DIETETICS. 

Thesis of Dietetics based on the principle of sparing the weakest 
part — I. Stomach — II. Intestines — III. Increase of ab- 
sorption — IV. Delay of absorption — V. Gradual return 
to normal diet. 

[Extra Course, St. Marys, Summer Session, 1857.) 

As a contribution toward clearing away the mistiness of our 
clinical dietetics, I purpose to set before you in one lecture cer- 
tain theses which are my guides in this matter, and perhaps, 
therefore, may help you also. 

The leading idea of the first-placed and most important rules 
is simply that of sparing weak members— working those that 
can work and resting those that cannot. 

I. 

When the stomach is off work, spare it, and leave the digestion 
as much as possible to the intestines. 

This applies to cases of weight and pain after eating, heart- 
burn, acidity, hsematemesis, vomiting of unaltered food, and fer- 
mentation. Should the conjunction of symptoms enable us more 
definitely to diagnose gastric ulcer, mucous flux, cancer, or any 
other more definite anatomical change, the application is all the 
more imperative. 

Spare the stomach both its mechanical and its chemical toil. 

The first is the hardest, and .therefore the most necessary to 
be avoided. A meal — that is, the laying in of victuals to avoid 



DIETETICS. 573 

future rather than present hunger — is a labor, even to the 
healthy ; so do not impose it on a sick stomach. In very bad 
cases, do not divide the daily allowance into meals* at all, but 
assign such quantity as appears enough for the twenty-four 
hours, and let the taking of it be spread over the whole time, 
as equally and with as short intervals as possible. In milder 
cases it will be sufficient to "spoil" the meals — that is, to take 
food between the usual times, so as to leave neither the necessity 
nor the inclination for eating at once as much as other people. 
One would be sorry to recommend to the healthy an overcare 
for their diet, but to invalids subject to gastric derangement, 
you cannot do better than advise an imitation of a famous cen- 
tenarian witness, examined by the scientific judge, who said he 
attained his great age by always " eating before he was hungry, 
and drinking before he was dry." 

But take care that your patients do not spoil their dinner and 
eat it too : that last error would be worse than the first. Make 
it a rule that the slightest sense of repletion is to be a warning 
to desist. 

Another valuable expedient for sparing the organ, in cases of 
slight indisposition, is dilution of the meal. Copious watery 
drinks carry the food on quicker through the pylorus, and give 
great relief to oversensitive, irritable stomachs. But at the 
same time it must be remembered that thus the time for the 
action of the gastric juice is shortened, and its chemical strength 
lessened, so that more is given for the intestines to do. It is 
better, therefore, to let this dilution be practiced as long after 
the meal as the case admits of. It should be avoided also as a 
general rule where an obstructed circulation impedes absorption 
of the water by the portal veins. Patients with dilated heart, 
for example, and some cases of anaemia and of diseased liver, 
suffer much inconvenience from a sloppy diet. Obese persons 
also should avoid dilution ; it washes away the albumen which 
they do want, and allows of the absorption of fat, which they are 
better without. 

* A Meal (as in Saxon " male," in German " mahl," and " mal") implies ap- 
portionment of food, time, or anything else. So Bacon — " the yearly rent is stil 1 
paid into the hanaper in parcel meal" — that is, "in lots." 



574 DIETETICS. * 

The chemical toil of the stomach may be spared by giving it 
less to digest, and more to digest with. Take care that the 
weak but well-meaning organ is not driven to despair by solid 
lumps of albuminous food. The best form of nitrogenous ali- 
ment in these cases is whey, or milk prevented from coagulating 
by a copious admixture of lime-water. This fluid meat will pass 
through the stomach unaltered, the gastric juice will trickle 
through the pylorus at its leisure after it, and with the intestinal 
juice will digest the casein in the intestines. Next in easy solu- 
bility comes soup, made fresh, weak, and at a low temperature 
— fresh, that it may not decompose ; weak, that it may be easily 
absorbed; at a low temperature, that it may not be filled with 
innutritions gelatine, or with hard-boiled albumen. Meat is 
suitable in proportion as it is soft, easily disintegrated, quickly 
cooked, and free from fat, which might oppose the soaking in of 
the gastric juice. The well-known list of Dr. Beaumont sets 
in the order of these qualities a great number of articles of 
diet. But I think it more useful for you to have the principles 
of selection than a mere experimental enumeration of the articles 
themselves. 

To mix starchy food with the albuminous in cases of weak 
digestion is an irrational practice. It soaks up the little that 
there is of the valuable gastric juice, and then makes no use of 
it ; for starch is quite unaltered by the peptic solvent. This is 
very bad economy indeed. Moreover, if taken in quantity suf- 
ficient to assist much as a nutriment, it is too bulky, and being 
converted into sugar by the saliva, turns acid in a mass, and 
puts a stop to further digestion. This is particularly the case if 
it is in solid coherent lumps, such as potatoes, soft bread, pastry 
and the like. 

Starchy food, unmixed with albuminous, is a different thing 
altogether. There certainly are some cases of gastric disorder, 
which are much benefited by a temporary adoption of such a 
diet. It is the best during acute catarrhal bilious attacks, at 
the commencement of treatment of even chronic gastric cases, 
and whenever a dusky complexion, hypochondriasis, or general 
distress, show that arrested moulting has caused a retention in 



DIETETICS. 575 

the body of effete tissues. It does good in fact as a temporary 
starvation. Hence you will see me occasionally begin the treat- 
ment of such cases by our " simple diet," and still oftener in 
private practice, where starvation for a time is more generally 
wanted than in hospitals, I give a patient nothing for two or 
three days but arrowroot, panada, tapioca, gruel, etc. This 
enables the congested portal system to disembarrass itself so 
as to leave a clear space for the taking up fresh supplies. 

As you return from a purely starchy, or purely animal diet, 
to that mixture of the two which is normal and necessary to the 
healthy condition, or if you consider that the case is not bad 
enough to oblige you to adopt either one or the other absolutely, 
you may be of use by so arranging that the two sorts of aliment 
shall not be together at once in the stomach. For example, let 
the morning and the evening diet be vegetable, and then let 
several hours pass before and after a mid-day meal of purely 
animal food. 

Spare thus the stomach by giving it less to digest. You need 
not be afraid of starving your patient by diminishing the quan- 
tity eaten. A little digested goes much further than double the 
amount only swallowed. For example, you saw last time we 
went around the hospital a girl in the corner of Victoria Ward, 
who had gained four pounds in weight during six days on the 
sole allowance of three pints of milk and less than twelve ounces 
of bread per diem. A man in Albert Ward has also visibly 
gained flesh in the same time, though he has only a pint of beef- 
tea beside what I mentioned as the girl's allowance. He is too 
weak to stand in the scales, but the increase is apparent to the 
eye. Both these patients had, till their admission to St. Mary's, 
been trying to strengthen themselves by meat, and whatever 
they could get, but having gastric ulcers did not digest it, and 
were rapidly emaciating. 

Spare it also by giving it more to digest with. I mean by 
supplying an artificial gastric juice. This is a mode of treat- 
ment so interesting, from our being enabled to use it with novel 
facility, that I shall make it the subject of a separate short 



576 DIETETICS. 

lecture,* and thus give fuller details of its practical working 
than I have time for to-day. 

II. 

When the f mictions of the small intestines are off w or 7c , spare 
them. 

Of acute diseases, this applies particularly to continued low 
fever (during both its height and its sequelae), to enteritis, diar- 
rhoea, and cholera; of chronic diseases, to ulceration, tubercular 
deposits, either in the peritoneum, Peyer's glands, or mesentery; 
and, secondarily, to disease of the liver. 

What are the functions of the small intestines in relation to 
different forms of aliment? and what colleagues have they that 
can be trusted to take their duties during a temporary holiday? 
The small intestines absorb all matters soluble in water and 
capable of endosmosis, and have in that work all the mucous 
membrane of the alimentary canal to assist them. They con- 
vert starch into sugar before absorbing it, in conjunction with 
the saliva and pancreatic juice. They dissolve albumen, and 
convert it into peptone, in conjunction with the stomach. But 
in the digestion of fat they have none to help them. 

All ordinary fats and oils, then, must be excluded from the 
dietary of patients affected with the last-mentioned diseases. 
Even cod-liver oil, so peculiarly wanted in phthisical cases, and 
so easily digestible, will often become rancid in ulcerated bowels, 
and aggravate the diarrhoea. If it does aggravate the diarrhoea, 
depend upon it more harm than good is done by the remedy; 
leave it off forthwith ; the case is an unsuitable one for it at that 
stage of the disease. And if cod-liver oil disagrees, a fortiori do 
other less digestible fats. I have known the mere skimming the 
fat from broth make all the difference whether it were digested 
or not, and the leaving off such a simple article as butter render 
a previously useless treatment immediately successful. 

Starchy food will agree only on the conditions that it is taken 
in small quantities, and that the saliva is in a state to do alone 

* See next Lecture. 



DIETETICS. 577 

what generally it has the small intestines to help it in doing. 
If the secretions of the mouth are deficient, it will not agree. 
Hence, in low fever, where the fauces and tongue are dry, you 
will never see me order arrow-root, bread, panada, gruel, potatoes, 
or any other amylaceous article. Where they are eaten they 
will be found unaltered in the faeces, and not rarely cause con- 
siderable aggravation of the symptoms. I have particularly 
observed this in convalescent patients after fever. You are 
often surprised by an unexpected relapse: examine the stools, 
and there you see lumps of potato, bits of pastry, or a mass of 
starch granules. The foolish friends have been disobeying orders 
and giving these articles, which cannot act as a nutriment, and 
do act as a poison. 

On the other hand, a phthisical patient, with a clean moist 
mouth, will generally digest such things well, in spite . of his 
ulcerated bowels, provided they are well chewed and not lumpy. 

Starchy food is exceedingly useful as a placebo to persons 
whom you wish to keep on low diet, such as rheumatic fever 
patients, for example. 

Albuminous food will agree, provided the stomach is doing its 
duty. But you must not forget that it has lost a potent colleague, 
and be careful to prepare the food so as to require only a short 
time in digestion. Milk must not be passed on to the small in- 
testines by being guarded with alkalies, but had better be soured 
and made into whey. Some of the curd, broken up quite small, 
may be taken with it. Frequent dilution with watery drinks, 
and the use of artificial pepsine are of eminent use in these cases, 
so as to insure the absorption of the food as quickly and as high 
up in the intestinal canal as possible. 

III. 

Where you wish to hasten absorption, dilute with water. 

This is so obvious a consequence of those laws of osmosis which 
almost every course of lectures — anatomical, botanical, physio- 
logical, medical — has occasion to recite, that I will spare you the 
repetition. 

The rule finds its chief application in fevers, but it must not 



578 DIETETICS. * 

be passed over in ulceration of the alimentary canal and other 
local disorders where protraction of the process is painful, or in 
emaciation and convalescence where we would not wish to waste 
time, but to give a person all the nutriment possible in the day, 

IV. 

When you wish to delay absorption, dilute with solids. 

For solids to act as diluents they must, of course, be incapable 
of absorption; and the substance I principally refer to is cellu- 
lose in its various forms of chaff, bran, husks, skins, seeds of 
fruit, and fresh green vegetables. Cellulose being incapable of 
chemical change there, passes unaltered through the alimentary 
canal, carrying with it first the chyme prepared for absorption, 
and then adding its bulk to the faeces excreted. Thus the ab- 
sorption is spread over a longer time and a larger surface of 
mucous membrane, the whole of which is brought equally into 
work. A collateral advantage is that the peristaltic wave acts 
with more regularity when it has a solid to propel than when 
the contents of the tube are fluid only. The rule is useful, not 
so much at the sick bed as for the prevention of sickness. Many 
persons are made ill by their diet being more immediately digest- 
ible than they have been used to. Scotch laborers on exchang- 
ing oatmeal for wheat flour, Finn recruits on getting bread at 
headquarters without birch bark in it, country persons on coming 
to London or Paris, often suffer from this cause. The mode of 
prevention is obvious and cheap; cabbage, brown bread, and 
charcoal offering types of remedies readily altered according to 
taste. 

In the administration of medicines something may be learned 
from the same expedient. Quinine occasionally will not agree 
where powdered bark or decoction of bark will yet succeed very 
well; and the same may be said of the soluble and insoluble salts 
of iron, of morphia and opium, and similar drugs identical in all 
but insolubility. I believe the secret is that a slower and more 
graduated absorption is gained. 

I have elsewhere* stated reasons for suspecting that gum and 

* " Digestion and its Derangements," book i, p, 260. 



DIETETICS. 579 

gelatine may be classed among unabsorbable diluents of the food, 
and are not really nutritious ; but the argument is hardly suited 
to a practical lecture. 

V. 

When the diet has been diminished, return gradually to the 
normal in quantity and quality. 

I suppose mere instinct teaches this, for all acknowledge the 
justice of it as a sort of truism, and agree that a convalescent 
diet should be "light" at first, and afterward more "substan- 
tial." Perhaps, in respect of quantity error is rare; but the 
spirit of the rule in regard to quality is often lost by misinter- 
preting the words "light" and "substantial." Scientific men 
must not think vaguely, and you must have clearer ideas than 
the old nurses, who so often hurt your patients by misapplying 
these expressions. I shall not, therefore, think I am wasting 
time by explaining what the rule really means. 

I formerly* divided foods into such as are capable of direct 
absorption without change, and such as require a previous change 
by the digestive juices; and the same division has also been 
adopted by M. Bernard. By subdividing the latter class into 
such as require only direct chemical change, and such as require 
disaggregation as well, we get three groups of aliments : the first 
the "lightest" or most digestible; the last the most "substan- 
tial;" the second intermediate. M. Bernard observes that the 
first necessitate but one physiological act ; the second, two acts ; 
and the last, three ;f and, consequently, in that order demand a 
proportionate amount of labor from the system. 

Under the first head come water, essential oils, tea, coffee, 
alcohol, ethers, salts, sugar, whey, gravy (containing osmazome) ; 
asses' milk, with its small quantity of butter and casein, and its 
large allowance of sugar, forms a transition, through cows' milk, 

* In " Digestion and its Derangements," book i, p. 195. 

f " Memoire sur la Question suivante mise au Concours, par le Societe de 
Medecine de Lyon, pour Tannee 1856, &c, &c," obtenue par M. le Dr. Bernard, 
fils. Lyon, 1857. 



580 DIETETICS. * 

to the second class, in which some soups, lightly cooked eggs, 
well-boiled liquid starch; in the third class, tripe, oysters, sweet- 
bread, and boiled chicken come nearest to the second, while the 
power of digesting hard meats (such as beef), or solid lumps of 
starch (such as potatoes), show that the full normal powers of 
digestion have been regained. This is something definite, and 
with this idea you will find no difficulty in making a graduated 
scale up which a convalescent patient may safely mount. 



LECTURE XLVIII. 

CORPULENCE. 

Obesity to be distinguished from fatty degeneration — Origin of 
adipose tissue from food either containing fat, or elements 
capable of conversion into it, in excess over the respiratory 
consumption — Presumed possibility of relief by dietetic 
treatment — Tendency to obesity congenital and hereditary — 
Deductions from thirty-eight tabulated cases as to the pecu- 
liarities of obese persons, and the exciting causes of their 
condition — Obesity a comparative hypertrophy arising out 
of a comparative vital deficiency — Principles of rational 
treatment thence deduced — Difficulties in enforcing their 
adoption — Specimen of detailed scheme of dietary — Limits 
to attempts at reduction — Drugs, such as liquor potassee, vin- 
egar, iodine, and diuretics, discussed — Belts and baths — 
Prognosis of 



[St. Mary's, Cc urse on Practice of Medicine, part of Lecture on 
"Hypertrophies" December 1, 1862.) 

As Gulstonian lecturer, I delivered at the College of Physi- 
cians, in 1850, a course of lectures on Corpulence, and published 
them in a little duodecimo afterward. As more than a dozen 
years have passed by, and the volume has been long out of print, 
I may be allowed to dish up some old matter, and to give you 
an analysis of the more practical parts of what I then said at 
fuller length before a more stately audience. 

In the first place, I carefully distinguished obesity, or the 
inconvenient presence of a large quantity of normal fat, from 



582 CORPULENCE. 

fatty degeneration of existing tissues. I traced the origin of the 
true adipose tissue, showing, by well-established physiological 
observations, that it is derived entirely from the food eaten, in a 
great measure directly, as fat previously ready made, and partly 
from articles, such as starch, readily converted chemically into 
fat. And I laid down the law, that for the formation of fat the 
preliminary need is that the materials be digested in greater 
quantity than is sufficient to supply carbon in equal amount to 
that consumed in the respiration. 

Thus you see I showed the probability that by modification 
of diet we may be enabled to govern effectually at will the forma- 
tion of fat in the human body. 

The next point I aimed at making was that the excess of fat 
which inconveniences a good many people owed its origin to a 
congenital, often hereditary, structure of body. The peculiar- 
ities of this structure of body are most manifested in the func- 
tions of the assimilating organs, especially in the intestinal ab- 
sorbents, which are more active than is consistent with the size 
of the body, and which are mostly concerned with the osmosis 
of oleaginous particles. It is impossible of course to demonstrate 
during life this important, perhaps the most important, pecu- 
liarity. But there are others which are capable of being made 
subjects of observation, and these I endeavored to make evident 
and to base upon fact by a table of notes I had made of the cases 
of thirty-eight obese persons then alive, or at least alive when 
the notes were written, and ranging in weight from about sixteen 
up to thirty-six stone (504 lbs.). 

From this table I drew the following deductions: 

1. That in corpulent persons the bony framework of the body 
is less massive than in the spare, as indicated by the smallness 
of their hands and feet. 

2. That the skin is usually fresh colored and thin, and the 
hair soft and fine. 

3. That in youth and middle age their digestive apparatus 
performs its task with rapidity. The action of the bowels is 
generally natural, and in some cases loose. But where the ac- 
cumulation of fat is principally in the omentum, a pendulous 



CORPULENCE. 583 

state of abdomen is apt to be produced, causing a displacement 
and dilatation of the intestinal canal that make it sluggish and 
irregular. 

4. That their respiratory function presents a well-marked and 
universal peculiarity. The volume of air which they are capable 
of containing in and expiring from their chest is considerably 
less than the average quantity contained and expired by healthy 
persons of equal height. The lungs, instead of holding an amount 
of air proportioned to the size of the body, seem of diminished 
power. "Thus the vital capacity of H. T. (No. 35), a man of 
enormous muscular strength, and in his youth remarkable for his 
power of wind, ought to have been at least 250 cubic inches; 
instead of that it is but 205. Ch. S. (No. 9) held but 120 cubic 
inches of air, whereas she ought to have contained 206, accord- 
ing to the table of healthy averages published by Dr. Hutch- 
inson. G. 0. R. (No. 18) when in perfect health, in 1845, held 
255 instead of 270 cubic inches." The lungs, therefore, in 
obese persons are small, and consequently their exhalation of 
carbon deficient. 

5. That the reproductive powers are by no means defective, 
some being very fertile and few barren. 

6. That a tendency to obesity is decidedly hereditary; though 
the actual disease is not always developed in every member of the 
family, and rarely before adult age. 

7. That of the exciting causes in those predisposed to it, none 
appears so common as the occurrence of an acute attack of ill- 
ness. Next surgical injuries, and next chronic diseases of such 
nature as to render confinement needful without injuring the 
constitution. 

8. Taking a large quantity of liquid, of any description, is 
another frequent cause of corpulence. Of course, if the liquid 
be fatty at the same time, such as in the case of milk, still more 
striking effects are produced. And the mixture of alcohol and 
sugar, such as we find in beer and sweet wines, makes an equally 
deleterious drink. 

9. Deficiency of sunlight has a similar effect. A case is cited 
from the table (No. 13) of a man employed in the cellars of a 



584 CORPULENCE. 

brewery, who, in spite of strict temperance, found his bulk be- 
come so great as to give him much alarm. He obtained a situa- 
tion as clerk in the same establishment, and found the employ- 
ment above ground cause a rapid reduction. 

It is made to appear by what has gone before that the accu- 
mulation of fat in the tissues is a partial and comparative hyper- 
trophy — comparative, that is, with the proportions of the other 
functions — connected with a comparative deficiency of the decar- 
bonizing force of the lungs at least, and possibly of other organs. 

Hence were deduced the principles of the treatment shown to 
be rational by physiology and efficient by experience. 

1. The dietary must be made the special object of care ; it 
must be habitually different from that of ordinary healthy per- 
sons, inasmuch as the obese differ congenitally from others. 

2. All oleaginous articles of food should be rigorously ab- 
stained from : fat, oil, butter, milk, cream, maize, and the like, 
must be entirely abstained from. Sugar must be left off. The 
amount of other hydrocarbons must be reduced to the minimum ; 
starch, in the form of potatoes, bread, &c, being looked upon 
with extreme suspicion. 

3. To avoid the transformation into fat of starchy articles of 
diet, which it is impossible wholly to shun, it is desirable that 
food should lie in the stomach as short a time as possible, in 
order that a fatty fermentation (so to speak) may not be set up 
in it. Therefore very light meals at not too long intervals should 
be taken, at times most favorable to rapid digestion, and should 
consist of substances easy of solution and assimilation. 

4. Liquids should be taken at the end, and not at the begin- 
ning of the meal ; so as not to impede the mixture of the gastric 
juice with the mass. 

5. The liquids taken should be small in amount. 

6. Inasmuch as excess of alcohol diminishes the excretion of 
carbon (as shown by Booker's experiments) the quantity taken 
should be limited to that found by experience in the case of each 
individual to quicken the digestion. 

7. Exercise should be taken to sufficient extent fully to em- 
ploy the muscles and lungs. But it should not exhaust com- 



CORPULENCE. 585 

pletely the strength, otherwise an imperfection of digestive 
powers is the result. 

8. The exercise should be taken in the open air and sunlight. 

9. As in the management of all congenital tendencies, medi- 
cines must be looked upon as wholly secondary to regimen. 
Those adopted should be such as tend to increase the meta- 
morphosis of fat and its habitual evacuation in the form of car- 
bonic acid. 

10. The quality of the food is of more direct importance than 
its quantity. 

The hourly watch over the instinctive desires, which must be 
observed by one desirous of reducing his corpulence, makes it a 
serious thing to advise the undertaking of the necessary regimen. 
Many of us shirk giving our advice, because we feel confident 
that the patient has not strength of mind to follow it. He that 
commences it must be taught to view himself as his worst enemy. 
Like Epictetus' philosopher, he must " mount guard and plot 
against himself." We must feel very sure we are doing what is 
right before we take such a responsibility, otherwise hesitation 
will produce wavering, and wavering shake the confidence of the 
patient, and all hope of benefit be lost. All advantages should 
be taken of adventitious circumstances : to add importance to the 
enforcement of the rules, they should be written out clear and 
exact, and enjoined as strictly as if they were moral precepts. 
If left to general and verbal instruction, their chance of being 
observed is small indeed. 

At the same time the dietary prescribed and the hours fixed 
for meals should not be such as it is impossible for men actively 
engaged in business to submit to. In detail you may lay down 
some such scheme as this — 

Breakfast to be taken early and to form a substantial meal, 
so as to prepare for the day's work. The solid part of it to con- 
sist of two mutton-chops with the fat carefully removed, grilled 
or plainly cooked, and captain's or ship biscuit. Sometimes a 
pigeon, a bit of game, or a fish of about the same weight, may 
be substituted for the mutton-chops. For liquid to follow, if the 
patient will take soda-water or plain water, so much the better. 
38 



586 CORPULENCE.* 

If he cannot get over his craving for a cup of tea, let him take 
it in the Russian fashion with a thick slice of lemon floating on 
the top instead of milk. 

Luncheon at one may consist of the same ingredients, only 
instead of so much liquid, a glass of half-and-half, sound claret, 
or burgundy and water is more agreeable as well as more whole- 
some. 

Dinner to be taken earlier than is usual now-a-days. Six 
o'clock is the best hour. Soup and fish must be eschewed, and 
plainly cooked mutton and beef, especially the former, made the 
staple of the meal. A bit of biscuit may accompany it, and as 
vegetables, those which contain much insoluble chlorophyll and 
little starch, as cabbage, lettuce, spinach, French beans, or celery 
in small quantity ; but no potatoes. In short, the dinner should 
be as much as possible that of a carnivorous animal. Sweets, 
pastry, eggs, and beer, must be avoided like poison. Next to 
water, claret is the best drink; champagne (according to the 
well-known writer on this subject, M. Dancel), the worst.* 

Here should end the serious feeding for the day. * A cup of 
Russian tea, or a water-ice, may be taken during the evening, 
but a glass of water or soda-water is better. 

The emptiness or sinking at the pit of the stomach felt by 
those who begin a diminished diet, and which they often are 
driven to remove by eating and often (still worse) by drinking, 
is best relieved by chewing a bean or two of coffee. A supply 
sufficient for all wants is easily carried in the waistcoat pocket. 
I do not think it advisable to burden the conscience of the 
patient by laying down the number of ounces of each food which 
should be consumed. The nature of the food is of more import- 
ance than its exact quantity, and the exhibition made by eating 
from scales is annoying to touchy persons. 

Some persons are able to do without the dinner at all, and 
indeed in 1850 I was inclined to urge the adoption of this plan, 

* M. Dancel cites an instance of a young lady who, with the intent of pre- 
serving her symmetry, fasted four days every week upon champagne and " mar- 
rons glacees" alone. Her outline grew out of all drawing with frightful rapidity. 
But she regained it on resuming a more rational diet. 



CORPULENCE. 587 

and to subsitute for it biscuits and water taken standing up or 
while walking about. This is not a scale of diet absolutely 
unattainable. A retired butcher and pugilist whose case I had 
tabulated (No. 35) had adopted it for some years with the great- 
est comfort to himself. He was able to work upon it in a most 
violent manner in a small garden he cultivated for himself in the 
suburbs. He had reduced himself from 20 to 17 stone; whereas 
his brother, who had not the same strength of mind, had increased 
to 23 stone. Persons of more refined education have, or ought 
to have, the same power over their appetites. J. B. (No. 7) re- 
duced himself from 22 to 18 stone, and has sometimes brought 
himself down to 17. But he found no particular advantage from 
being of the lower weight. 

This latter remark leads me to observe that in all persons 
there is a certain weight, to be found by experience, called by 
trainers " the fighting weight," necessary to full force, and that 
to be lighter than this tends to injury of body and mind. And 
I must also say that mental workers do not bear abstinence so 
well as bodily workers, and that I do not think it advisable for 
a man whose mind is much engaged to attempt the omission of 
the usual evening meal. But he may at it feed his nervous sys- 
tem with meat, and not his adipose tissue with starch and oil. 

As to more strictly medical remedies, I have found full doses 
of liquor potassse at the beginning of the treatment very bene- 
ficial, especially in persons who are incapacitated by bodily in- 
firmity from taking sufficient exercise. I presume that it acts 
by increasing the vital powers of metamorphosis, by saponifying 
in part the fat contained in the blood and enabling it to be burnt 
off as carbonic acid. But I must repeat again that the pre- 
scription of drugs is strictly secondary to that of diet. Where 
the size of the abdomen impedes the walking, a belt, such as 
pregnant women wear, is useful. A few sweating baths are also 
beneficial at the commencement, as they bring the skin into good 
condition ; but as an habitual resource they are debilitating. 

Of vinegar and iodine as medicines I have no good to say. 
The moderate use of iodine certainly does not cause the disap- 
pearance of healthy fat. Indeed, it has been noticed by Lagol,* 
* " Essays," translated by Dr. O'Shaughnessy. 



588 CORPULENCE. 

and is matter of daily observation at our metropolitan hospitals, 
that patients frequently acquire a considerable amount of em- 
bonpoint during the time they are taking iodine. The cases of 
tumors and of fat are very distinct. As Dr. Pereira remarks,* 
" The enlargements which these agents (mercury and iodine) 
remove are not mere hypertrophies ; their structure is morbid, 
and they must in consequence have been induced by a change 
in the quality of the vital activity ; in other words, by morbid 
action. Medicines, therefore, which remove these abnormal 
conditions, can only do so by restoring healthy actions." But 
the action which causes the deposition of fat in the adipose tissue 
is of a healthy nature, and harm rather than benefit is to be 
expected from the drug under discussion ; that harm which 
always accrues from a valuable remedy wrongly employed. 

Of diuretics, as recommended by the older physicians, I have 
no experience. But as there is no secretion by which less fatty 
matter is excreted than that of the kidneys, they do not seem to 
promise well. 

The prognosis depends very closely upon the age at which the 
obesity has commenced. To that form of the disease which begins 
at birth, and goes on increasing during infancy and childhood, 
cure is unattainable. It is a sort of monstrosity, and the subjects 
of it usually display some other bodily malformation or a de- 
ficiency of intellect. When it begins in childhood or about the 
time of puberty, we must not be deterred, by the circumstance of 
its being hereditary, from trying to remedy the inconvenience. 
We cannot truly reduce our patients entirely to the average size 
and weight, but we may enable them to pass life in comfort and 
usefulness. 

The later the disease begins, the more controllable it is by 
management ; until the prime of life is passed, and then old age 
impedes in some degree the benefit we may confer, not by ren- 
dering our measures inert, but by preventing our employing 
them quite so actively as we should have done earlier. 
* " Materia Medica," vol. i, p. 196 (edit. 1848). 



LECTURE XLIX. 

ON PEPSINE. 

History of the use of gastric juice in medicine — Difficulties of its 
use obviated by preparation — Experience of its use in a feiv 
typical cases — Limits of advantages gained — Details of ad- 
ministration. 

(Extra course, St. Mary's, Summer Session, 1857.) 

The attempt to turn the peculiar powers of gastric juice to 
advantage in medicine dates from remote antiquity. Pliny 
mentions the fluids of the stomach of sucking animals as in com- 
mon use for a variety of purposes, such as curing disorders of 
the intestines, allaying the inflammation from spiders' bites, 
stopping bleeding from the nose, preventing snakes attacking 
you, and in short against poisons in general.* Asclepiades also 
recommended it as a means of dissolving milk which has clotted 
in the stomach in dangerous excess, f Galen, arguing probably 
on his physiological theories, attributes a " digestive" and " dry- 
ing" power to it. But he also mentions having felt in his own 
person the relief afforded by it to weight at the epigastrium after 
drinking too much milk, and advises a trial of it in abdominal 
disorders. He remarks that the stomach of one animal differs 
from another only in degree of power. He gives a warning also 
that the boiling temperature destroys its virtues, as we now well 
know ; for he found that hens' and cormorants' stomachs, when 
cooked, were perfectly inert.J 

* See the places referred to in any good index to Pliny's " Naturalis Historia," 
article " Coagulum." 

f Quoted in " Galen on Antidotes," ii, 7. 

% "Galen on Simple Medicines," s, 11; si, 13. 



590 ON PEPSINE. * 

On the strength of his rational advice the coagulated milk and 
fluid taken from the paunches of several young animals was a 
remedy sufficiently often used to retain a place in European 
pharmacopoeias up to the first quarter of the last century. This 
is the explanation given by Dr. Schroder, a Dutch pharmacol- 
ogist, who wrote in 1672,* of the method of preparing, and the 
reason for using, " Coagulum leporis,~\ hsedi, agni, equi" &c. 

The disagreeable nature of the remedy in this form probably 
drove it out of use, for the last London pharmacopoeia in which 
it appears is that of 1677. In the edition of 1721, the only re- 
presentative of gastric juice is the mucous membrane of the hen's 
stomach — " Pelliculse stomachi gallinde interior e%."% In 1746 
this also had vanished, along with " stercus bovinum, humanum, 
pavonis" and various similar remedies which patients had got 
too civilized to submit to, without at least knowing the reason 
why. Thirty years later, the immortal experiments of the Abbe 
Spallanzani threw a bright new light into the subject of di- 
gestion, and taught the true nature of the gastric juice. With 
much juster views than of old, its use in medicine was again rec- 
ommended. Dr. Mongiardini, of Pavia, a pupil of Spallanzani's, 
at his master's instance treated indigestion successfully with the 
gastric juice of crows. Another pupil employed it as alithontriptic, 
to break down calculi by destroying the animal matter which 
holds them together. M. Senebier, a clerical pupil, suggested 
that its antiseptic power might make it useful in surgery, and 
advised a trial of sheep's paunch as an application to ill-con- 

* " Pharmacopoeia Medico-Chemica." Amstelodami, 1672. 

| The rennet of the leveret is now usually wasted, but the Roman dairymaids 
preferred it to that of any other animal for making cheese. Varro ranks it as 
the best, then that of the kid, then that of the lamb. (Varro de " Re Rustica," 
lib. ii, xi, 4.) The Roman physicians also had the same preference. Sammonicus, 
in a prescription for " Colus" (Colic), says, " Aut pavidi leporis madefacta coagula 
pota." ("Quinti Serini Sammonici de Medicina Praecepta," " De Colo com- 
pescendo.") This accounts for its being named in pharmacopoeias which omit 
other rennets, as for instance in the Vienna priced drug list of 1613 and 1646, 
in which its price varies from six to sixteen kreutzers the half ounce. 

+ This is another Italian expedient for coagulating milk rarely used now. 
Palladius recommends it for making summer cheese, when you cannot get 
leveret's rennet. ("Paliadius de Re Rustica," "Mensis Maius," ix.) 



ON PEPSINE. 591 

ditioned wounds.* M. Boyer, of Strasburg, found that it de- 
stroyed the poison of the viper, and thought it might be an 
antidote to snake bites. f 

With all the obvious advantages with which the remedy rec- 
ommended itself to the physician, there was the insurmountable 
difficulty of obtaining it in a form fit for general use internally. 
It was of course necessary to administer it at the same time with 
the food, and any nauseating substance then given does more 
harm than good by taking away the already squeamish appetite. 
Dr. Latham, who practiced in Paris some years ago, informed 
me that Laennec had a preparation of concentrated gastric 
mucus, which he recommended with great enthusiasm ; and Dr. 
Handfield Jones at this hospital gave in some cases a cold in- 
fusion of pig's stomach, acidulated with muriatic acid. In this 
form, however, the remedy is disagreeable and inelegant. 

But the matter showed itself in quite a new light when an 
ingenious French pharmacien, M. Boudault, at the instigation 
of Dr. Corvisart, made the very elegant and agreeable prepara- 
tion, called " Poudre nutrimentive." It is simply pepsine from 
the sheep's stomach dried on starch, with lactic acid added or 
not according to circumstances. You have during the past winter 
(of 1856-7) seen me prescribe it to numerous patients in the 
wards, and I have also employed it frequently in private prac- 
tice, so that I think we are in a position now to form an idea 
of its value to the practical physician. 

These hospital cases in which I have administered it with ad- 
vantage are, six of phthisis pulmonalis, one of cancer near the 
pylorus, two of gastric ulcer, one of hysterical vomiting, two of 
nausea, one of hysterical pain after eating, two of atonic pain 
after eating, one of atonic gout, one of dilated stomach, one of 
gastric flatulence, three of low fever, and two of pneumonia. In 
these the full benefit which physiological reasoning would lead 
us to expect from the remedy has followed. 

[These cases fairly represent my since experience of the 
remedy.] 

* "Experiences sur la Digestion de l'Homme, par l'Abbe Spallanzani, avec 
des Considerations," &c, par Jean Senebier. Geneve, 1783. 
f Falck " Handbuch der Arzneimittellekre," vol. i, p. 275. 



592 ON PEPSINE. * 

I have also injected it per anum, mixed with food, in a case of 
ulcerated oesophagus, and in a case of manio-hysterical vomiting 
and dysphagia. But in neither did it appear to delay death. 
Probably the patients were already too far gone. 

Several other cases of atonic pain after eating, in which I 
have given pepsine, I have not since heard of, but probably 
should have done so had any harm happened. 

In one case of chronic dysentery it was stated to cause nausea 
and loss of appetite. In one case of consumption, and in one of 
pendulous tumor of the abdomen, it purged the patient. These 
are the only instances of inconvenience that I have been able to 
connect with the administration of the remedy. 

The phthisical cases have been those where a progressive 
anaemia was accompanied by an inability to digest meat or other 
albuminous food. This inability is exhibited in three ways : 
first, by meals of such diet, even in very small quantities, being 
followed by a sense of great weight and oppression at the epi- 
gastrium, and sometimes by actual vomiting; secondly, by the 
passage of loose fetid stools containing much unaltered muscular 
fiber, lumps of fat, and such like remnants of a recent meal ; 
thirdly, by entire loss of appetite and an instinctive nausea 
roused by the bare idea of flesh food. Often all three phenom- 
ena exist together ; but each one may be found separately, and 
is of itself a sufficient indication of the patient's state. 

The state of the stomach when these symptoms occur is 
probably an excessive secretion in the upper part of the aliment- 
ary canal of alkaline mucus, which envelops the food, and pre- 
vents the action of the gastric juice upon it. The consequence 
is, either its rapid ejection unaltered, or its decomposition, and 
the evolution of fetid gas. If vegetable food be mixed with the 
meat, it ferments into acetic acid, and thus you may have sour 
eructations from the stomach, and diarrhoea arising out of the 
want of gastric juice. If this excessive secretion of mucus is 
recent and moderate, the appetite may remain uninjured, nay, 
may sometimes be morbidly increased ; but a long continuance, 
joined to progressive pulmonary disease, is sure to induce an 
anaemic condition of the alimentary canal, which results in a 
disgust for food. 



ON PEPSINE. 593 

Now this state of things it is very important to check. If it 
goes on, the patient cannot take in sufficient quantities the meat 
which should refresh his degenerating muscles and pale blood ; 
he cannot take the cod-liver oil which is to replace his emaciating 
tissues ; he cannot, from weakness, take the exercise which might 
renew his whole diseased system. And I clo not know any 
remedy which more readily, obviously, and directly does what 
it can toward checking such a state than pepsine. It does im- 
mediately and surely what it can do ; but then that is not very 
much. Raise not your expectations of its power too high, or 
you will be disappointed. Understand clearly what position 
this agent holds in the rational materia medica, and then you 
will know what good results you may demand with reasonable 
hopes of obtaining them. It is an artificial, and therefore a 
partial, substitute for a natural process. Gastric juice prepared 
by a healthy animal is mixed with the food, instead of that 
which the patient's stomach ought to prepare. And it acts in 
the body just as it would out of the body under the same cicum- 
stances of heat and motion. The chewed meat is dissolved by 
it just as you see the white of egg suspended in this beaker dis- 
solved by it; and the putrefactive process is arrested by it in the 
intestinal canal just as you perceive the putrefactive process is 
arrested by it in the experiment under our eye. For you may 
observe that this albumen suspended in pepsine is quite sweet, 
whereas that soaked for the same time in saliva is most fetid. 
It is, therefore, a substitute for the natural secretion, and to a 
certain extent supplies its place. 

But, like all imitations of nature, it is coarse and imperfect. 
The solvent, instead of being gradually and continuously poured 
on to the outside of the mass of food, is mixed up in the middle 
part of it, and acts merely chemically, without any of the me- 
chanical and physiological helps belonging to natural digestion, 
and consequently soon exhausts its energies. The chyme, or 
albumen prepared for absorption, instead of being wiped off and 
swept away by the stomach, remains for some time mixed up 
with the pepsine, so that the latter is not freed for the solution 
of a new portion. By this imperfect process only a very small 
portion of meat can be dissolved at once. 



594 ON PEPSINE. * 

Hence, if you hope that by administering pepsine with it, you 
can get a full and sufficient meal eaten at once by your consump- 
tive patient, you will fail in your expectations. Give half a 
mutton-chop with the remedy the first day ; and if that is di- 
gested well, a whole chop next ; but then you have got to the 
end of your tether, and the digestion of a larger quantity will 
not be at all assisted by artificial solvents. After a chop has 
been digested and absorbed twice, or even once a day by this 
means for about a week or ten days, the expedient has prob- 
ably done all the work that can be fairly asked of it, and the 
stomach has either recovered sufficient energy to digest alone, 
or will require different remedies to enable it to do so. There- 
fore, for the pepsine to be completely successful in these cases — 
first, it must be given only to those who cannot digest half a 
mutton-chop without it ; secondly, more than a chop must not be 
given at once ; thirdly, it must not be required to go on alone 
improving the patient's condition for more than a week or ten 
days. 

But for the time named I advise its being given alone, and 
the action not interfered with in general by other drugs. Many 
will really prevent its chemical effect, and all will confuse your 
judgment of the advantage gained. In this time you will 
generally find that the repugnance of the patient to meat has 
been overcome, and that a small quantity of it at a time can be 
relished and digested ; the morbid fetor of the stools diminishes, 
and the flatulence and distress arising during their passage 
through the bowels ceases. A renewed strength and a renewed 
power of assimilation commence, the sleep becomes more natural, 
with the diminution of night-sweats and hectic ; while, at the 
same time, the pulmonary symptoms of cough, dyspnoea, &c , 
relax, and a step at any rate is taken in the right direction 
toward the cure of the disease. It is remarkable, too, what a 
slight improvement in the digestive pow r ers will often enable 
iron and cod-liver oil to be taken. These drugs are, you know, 
the main stays in the treatment of tubercular consumption, and 
any expedient, however temporary, which will pave the way for 
their administration, is a great boon. 

It would not suit the plan of the present lectures to quote in 



ON PEPSINE. 595 

detail these consumptive cases. They differ much from one 
another in their unessential characters — namely, in the stage 
and general phenomena of the disease, in age and sex of the 
patients; while they all closely resemble one another in essential 
points — that is to say, in those which I have described as indi 
eating a mucous condition of stomach, preventing the gastric 
juice being poured out on the food, and finally leading to ansemia 
and atrophy of the secreting membrane. They resemble one 
another also in exhibiting an immediate and uniform ameliora- 
tion of limited extent. In one man who had loss of voice, ap- 
parently from crude tubercle in the lungs, with ulcerated trachea, 
the amelioration of voice and cough continued so long, that I let 
him remain three weeks taking pepsine alone without other drugs ; 
but, then, he also continued to improve more afterward on cod- 
liver oil, so that he might just as well have commenced it sooner. 
In another, who had tubercular ulcers in the bowels, afterward 
fatal, there was an idea that the pepsine caused a relapse of 
diarrhoea ; but I suspect the coincidence was accidental. These 
are the only cases where it appeared to do more good or less 
good than I have attributed to it. 

The case I alluded to of cancer near the pylorus is an instance 
of a disease necessarily fatal being still worthy of the careful 
attention of the medical man. When the patient came under 
my care, she was unable to keep anything at all on her stomach : 
every solid, even an ounce of beef-tea, was vomited unchanged 
within half an hour of its ingestion. She had been taking prus- 
sic acid, soda, creasote, opium, and a variety of remedies with- 
out benefit ; and, as might be expected, was dying rapidly of 
starvation. I ordered her immediately half a, mutton-chop, with 
fifteen grains of Boudault's " poudre nutrimentive," twice a day, 
and an ounce of milk and lime-water every two hours. She kept 
all that down ; it passed the pylorus, and nourished her so far 
that she had a good night's sleep, and the next day was able to 
take a whole mutton-chop. So she went on for three weeks, 
gaining flesh, losing her pain, and acquiring a cheerfulness about 
the future unwarranted by the gloomy prognosis which truth 
compelled me to give her. So far all was right ; reason had 
reasoned well. But I feel it a duty to tell you the mistakes I 



596 ON PEPSINE. 

make, as much as the occasions on which I act wisely. And I 
find recorded in my note-book a warning, which I advise you to 
profit by, of the importance of " letting well alone." The patient 
from the first had jaundice, with pale stools and bilious urine ; 
and now, I thought, had sufficiently recovered strength to bear 
an endeavor to make the liver clear the blood of its bile a little 
more briskly. I therefore gave her some nitro-hydrochloric 
acid, which is often of great use under similar circumstances. 
But the result was most unfortunate. The vomiting returned 
with violence. The drug was left off, and the vomiting stopped, 
but not before the ground gained had been lost. Then again, 
contrary, I must say, to my wish, it was judged expedient to 
give the patient mercury, and she rapidly sank. The jaundice 
was then proved to be dependent on cancer of the gall-bladder. 
Now, here it is impossible not to allow that life was lengthened 
by artificial pepsine, and would have been further lengthened 
but for a meddlesome propensity in both physician and patient 
for continuous improvement. 

In one case of hysterical vomiting, and two of nausea prevent- 
ing a due quantity of food being taken by hysterical persons, 
this remedy has appeared to enable the patient to swallow meat. 
The mere nutriment thus imbibed has improved the appetite for 
future meals; and the valerian and salt sponge-baths afterward 
administered seemed to have a more rapid effect than without it. 
The rational explanation of its good influence is, that both in 
hysteria and anaemia the secretion of gastric juice is apt to be 
irregular and deficient, and that the morbid processes here act, 
as is so often the case, in a circle ; the non-secretion of gastric 
juice still further starving the blood and aggravating the hysteria 
and ansemia, and that further aggravation again diminishing the 
secretion. But once breaking the magic chain, and enabling 
even a single meal to be well digested, begins a march toward 
health which it is comparatively easy to guide afterward. 

Closely connected with the last-named complaints is, in the 
female sex, atonic gastralgia. Indeed, I may say it is practically 
identical. At the same time that the gastric juice is imperfectly 
secreted, the muscles of the stomach refuse to perform the peri- 
staltic motions with sufficient activity. Hence not only is the 



ON PEPSINE. 597 

alimentary mass a greater inconvenience than it ought to be, but 
it actually lies longer than usual in the first portion of the canal, 
as may be found on percussion of the epigastrium. Atonic gas- 
tralgia is a common consequence, in the educated classes, of ex- 
cessive mental and sedentary labor. Where this is very great, 
I have found pepsine of some use ; but in the slighter cases, which 
more frequently come before us, I have not seen any apparent 
benefit accrue from it. A change of habits is here the only per- 
manent remedy, and of drugs strychnine is the most efficacious. 
I believe M. Boudault prepares a powder in which strychnine is 
combined with pepsine and lactic acid. I presume it is for cases 
of this sort that it is intended, but I have not tried the combi- 
nation. 

In a case of diarrhoea and mucous vomiting occurring in an 
old victim of atonic gout, the stools became more natural and 
less frequent, and strength was regained, on taking pepsine and 
mutton-chops, instead of opium and acetate of lead. 

As cases of acute disease have a habit of getting well of them- 
selves, they are not, of course, such good tests of the essential 
benefit derived from remedies; and it is only by comparisons on 
a large scale that one could speak of fever and pneumonia being 
benefited by pepsine. There seemed, however, in those alluded 
to, an immediate improvement to take place in the appearance 
of the tongue and of the evacuations; and it is impossible not to 
think that the amelioration in the alimentary canal thus made 
evident would tend to lessen the mortality of these diseases. 

On the whole, then, I cannot but conclude that we have in 
artificial pepsine a valuable and safe remedy, and an important 
aid to rational medicine. 

The way in which I have given it has depended on the diet 
on which the patient is placed. If regular meals are eaten, then 
it is best taken spread as a sandwich between two thin slices of 
bread at the commencement of the dinner. Fifteen grains of 
the starchy powder is the usual dose for an adult. If the patient 
is so ill that the food is obliged to be administered more fre- 
quently and in small quantities, so as to keep up a continuous 
supply, smaller doses of the pepsine powder may be given in a 
draught every four or five hours. 



LECTURE L. 

ON ALCOHOL. 

Experiments showing the action of alcohol on the vital metamor- 
phosis of the body, with a running commentary on each — 
Opposite opinions about the use of alcohol — Best guide to 
therapeutical use is physiological observation of its action on 
the healthy body — What is a stimulant? — The effect of 
alcohol is arrest of nervous function — How it comes to be an 
indirect restorative — Rules for the administration of alcohol — 
Form of administration. 

(St. Marys, 1861.) 

The porter of our school and the late Mr. Hall Smith assisted 
me, in 1860, in a series of experiments on the effects of alcohol. 
The melancholy circumstances of the latter's death brought them 
to an abrupt termination, and made the prosecution of the in- 
vestigations painful to me. But still let us see what can be 
done with the facts already collected, and try whether they can 
be made of service to clinical medicine. 

I. — W. M. Age thirty-eight. Weight 254 lbs., taken at noon 
every day. Habits of life extremely regular. He walks half an 
hour before breakfast, daily ; breakfasts at eight on two cups of 
coffee, bread and butter, and a slice of cold meat; dines at one 
on beef and mutton in regular quantity, potatoes, and pudding; 
has tea at five, two cups, with bread and butter ; sups at nine, 
on bread and butter, or cheese, with half a pint of ale. He 
sleeps six and a half to seven hours. His bowels are open once 
daily. 



ON ALCOHOL. 



599 



A view of the normal amount of metamorphosis in the body is 
afforded by this table: 





Quantity- 
iii citric 
centi- 
metres. 


Specific 
gravity. 


Urea in 
grammes. 


Chloride 
of sodium 

in 
grammes. 


Sulphuric 

acid in 
grammes. 


Phospho- 
ric acid 
in 
grammes. 


Uric 

acid 

in 

grms. 


Amount of urine and 
its several parts 
made in 23 days, in 
perfect health and 
on usual diet, . . 

Ditto in 15 days, . . 

Mean daily amount, . 


24,970 
1,085 


23-518 
1-022 


728-437 
31-671 


174-625 
7-592 


51-307 
2-230 


44-719 
1-944 


2-813 

•187 



The effect of the addition of a moderate quantity of alcohol to 
the daily meal is shown by the next: 



Sept. 13 
" 14 
" 19 
" 20 
" 21 
" 22 



Quantity 
in cubic 


Specific 


Urea in 


Chloride 
of sodium 


Sulphuric 


Phospho- 


Uric acid 


centi- 
metres. 


gravity. 


grammes. 


in 
grammes. 


grammes. 


grammes. 


grammes. 


1,020 


1-024 


30-708 


7-140 


2-017 


1.469 




1,570 


1 022 


39 746 


10-990 


2-579 


•848 




1,050 


1-026 


38-795 


8-400 


2-456 


1-890 


■ -1 


1,200 


1025 


42-695 


9-600 


2-622 


1-944 


1 


1,110 


1-023 


37-974 


6-937 


2-212 


1-798 


770 


1-026 


30-030 


6-160 


2-065 


1-386 


■ J 



Daily quantity of best 
French brandy added to 
meals in ounces by mea- 


sure. 


4J 


o 


6 viz., 1J at 


breakfast, din- 


ner, tea and 


supper. 



On the next day the appetite for food was observed to be some- 
what less than usual, and the experiment ceased ; for any change 
of usual weight, health, feeling, or habits, of course would vitiate 
the result of an investigation conducted in this form. 

These few experiments lead to the belief that the taking a 
moderate quantity of alcohol with food — 

(1st.) Increases the quantity of urea daily excreted, and in a 
much minor degree that of the chlorides and sulphates. 

(2d.) It does not increase the aqueous part of the urine. 

(3d.) It decreases the quantity of phosphates. 

(4th.) The augmentation is temporary, and after a time is fol- 
lowed by a reduction to the normal measure, which reduction is 
coincident with a loss of appetite. 

The increase in the quantity of urea excreted would seem to 
show that the renewal of the muscular tissues, the appropriation 
of new flesh, and the removal of old flesh, go on more actively 



600 ON ALCOHOL. * 

for making a moderate quantity of alcohol part of the daily 
food. 

The non-increase in the aqueous secretion, and the decrease 
in the phosphates, would seem to show that this change is not 
merely a general augmentation of the destructive metamorphosis 
of the body; for if it were, the whole of the constituents of the 
urine would be equally affected. 

In short, the circumstances seem to indicate that a moderate 
dose of alcohol acts by temporarily augmenting the digestive 
power of the stomach, helping it to appropriate more thoroughly 
the food. 

The decrease in the excretion of phosphates is an interesting 
observation. The chief source of phosphorus in the urinary ex- 
cretion must be nerve tissue, and it is certainly something more 
than a mere coincidence when we see a reagent, whose effects 
are most peculiarly manifest on the functions of the nerves, 
diminishing what we believe to be the metamorphosis of that 
portion of the body. We can hardly hesitate to call alcohol an 
arrester of nerve-life, and consequently a controller of nervous 
action on the rest of the frame; and it would be wise to cast 
about for explanations which would harmonize this with its other 
operations. 

II. — Letitia C, a prostitute, aged twenty-three, acquired the 
habit, during a year of her being on the town, of frequent tip- 
pling to drown care. Standing by her bed on the 14th of August, 
she suddenly fell on to it, not from apoplexy, but from complete 
paralysis of the right leg and arm without a fit. On her admis- 
sion to St. Mary's, two days afterward, the power had returned 
in a great measure to the limbs, but the right lingual and facial 
muscles were still quite paralytic. As far as one could judge 
by external phenomena, all the viscera except the brain were in 
a healthy state. She stayed in the hospital till September 6, 
when she was offered a place as servant, and a slight impediment 
to speech remaining I considered not sufficient reason for her 
passing over so good a chance of bettering her social state. 
During the time she was under observation no drugs were pre- 
scribed for her; she rested on her bed the greater part of the 



ON ALCOHOL. 



601 



day, and sauntered about the ward and garden the rest; she was 
kept on "broth diet."* 

The amount of urine and of its chief constituents excreted by 
her on all the days when circumstances allowed it to be all col- 
lected is shown in this table : 



Date. 


Quantity in 
cubic 


Specific 


Urea in 


Chloride of 
sodium 


Sulphuric 
acid 


Phosphoric 
acid 




centimetres. 


gravity. 


grammes. 


in grammes. 


in grammes. 


in grammes. 


Aug. 17 


252 


1-018 


5-915 


1-389 


? 


•409 


" 19 


880 


1-006 


12-729 


4-400 


? 


•396 


" 20 


240 


1-014 


4-529 


2-040 


? 


None. 


" 21 


270 


1-007 


3-429 


•337 


•206 


•061 


" 22 


360 


1-011 


5-280 


2-340 


•212 


A trace. 


" 23 


1,000 


1 007 


15-353 


3-500 


•878 


•540 


« 24 


1,280 


1-007 


14-504 


4-480 


•715 


A trace. 


" 27 


570 


1-008 


9-405 


1-425 


•436 


A trace. 


» 28 


1,030 


1-007 


10-979 


3-862 


•596 


•494 


" 29 


730 


1-010 


9-252 


3-285 


•423 


A trace. 


" 30 


1,320 


1-008 


13-645 


5-120 


1-039 


? 


Sept. 1 














" 2 
" 3 


1,650 


1-008 


22-027 


1-358 


7-425 


? 


" 4 
" 5 


900 


1-010 


13-231 


2-925 


•790 


•162 



It will be noticed that in the last three observations there is 
an improvement in the amount of those solid constituents of the 
urine which are an evidence of the force of vital metamorphosis. 
This improvement was coincident with the addition of three 
ounces of brandy to her diet card, an ounce and a half at dinner, 
and an ounce and a half at supper daily. 

In this case, then, we again find alcohol appearing to aid vital 
force of metamorphosis when taken with food. The quantity of 
urine, of solid matter in it, of urea, of chloride of sodium, and 
of sulphuric acid is augmented. The phosphates, truly, are 
remarkably deficient, but that probably depends on the arrest 
to the renewal of brain substance which the injury to her brain 
entailed. 

III. — The first subject, W. M., at another time tried the effect 
of alcohol taken in another way, namely, in small divided doses. 

* Tea, 2 pints, with 3 oz. of milk, and sugar q. s ; Bread, 12 oz.; Butter, f of 
an oz.; Broth, 1 pint, with 4 oz. of boiled meat; Gruel, 1 pint. 
39 



602 



ON ALCOHOL. 



Six ounces of brandy were drunk daily in drams of half an ounce 
every hour from 9 a.m. to 9 p.m. 
This is a record of the results: 





Quantity 






Chloride of 


Sulphuric 


Phospho- 


Uric 




in cubic 


Specific 


Urea in 


sodium 


acid 


ric acid 


acid 


Date. 


centi- 


gravity. 


grammes. 


m 


in 


in 


in 




metres. 






grammes 


grammes 


grammes. 


grammes. 


Aug. 18 


1,520 


1-013 


30-465 


5-320 


2-210 


1-299 


•008 


" 20 


910 


1-025 


33-077 


6-370 


2 375 


1-474 


•259 


" 21 


1,070 


1-022 


32-945 


6-687 


2-246 


1-637 


•193 


" 22 


1,000 


1-021 


23-735 


6-750 


1-897 


1-440 


•135 


" 23 


1,310 


1-015 


25-097 


7-205 


1-649 


1-061 


•196 


" 24 


1,530 


1-021 


41-867 


9-945 


3-064 


2-203 


•390 



One day was an interval in the experiment, and only the 
usual amount of daily diet, without extra alcohol, was taken, 
when the numbers stand as follows: 



Date. 
Aug. 19 


Quantity 
in cubic 
centi- 
metres. 


Specific 
gravity. 


Urea in 
grammes. 


Chloride of 

sodium 

in 

grammes. 


Sulphuric 

acid 

in 

grammes. 


Phospho- 
ric acid 

in 
grammes. 


Uric 

acid 

in 

grammes. 

•281 


920 


1-026 


35-88 


5-750 


2-374 


1-904 



It is very clear from these observations that alcohol taken in 
the dram-drinkers' fashion, namely, in small divided doses, by 
no means increases metamorphosis. It rather tends to diminish 
it, and this diminution is not sudden or immediate, but is more 
and more for a certain period, till the retention reaches a point 
at which a critical discharge takes place in healthy persons. 
This discharge may take place either in consequence of the alco- 
hol being left off, as may be observed in the day of interval ; or 
from an idiopathic reaction, as on the 24th of August. This 
idiopathic reaction was in the present instance doubtless enhanced 
by the excitement of packing up for a short visit to the country 
which began on the next day, and removed the subject from 
observation. 

On the whole, we may conclude that the effect of continued 
small doses of alcohol is to diminish vital metamorphosis, to make 
it irregular, and to induce, in healthy people, the necessity for 



ON ALCOHOL. 



603 



crises of evacuation. Its first action is upon the stomach, ena- 
bling more food to be digested, and increasing vitality ; but if 
advantage is not taken of this first action, its secondary effect is 
a diminution of vital functions in general, and of digestion 
among their number. 

IV. — These opinions are further supported by the following 
set of experiments : 

T. K. C, aged forty-three, healthy, though not muscular, of 
regular life and habits, took daily during the days averaged in 
the table a quantity of food proportioned to appetite, viz., about 
a pound and a half of meat, half a pound of bread, a pint and a 
half of tea, with milk, sugar, butter, sauces, &c, q. s., half a pint 
of water, and from five to seven glasses of port or sherry ;* care 
being always taken not to annoy the temper, and so nullify the 
experiments, by overstrictness. 





Quantity 
in cubic 
centi- 
metres. 


Specific 
gravity. 


Urea in 
grammes. 


Chloride of 

sodium 

in 

grammes. 


Sulphuric 

acid 

in 

grammes. 


Phospho- 
ric acid 
in 
grammes. 


Uric 

acid 

in 

grms. 


Amount of urine 
and of its seve- 
ral parts made 
in 15 days, in 
perfect health 
and usual diet, 


18,800 


15-337 


493-852 


137-655 






Ditto in 14 days, 










26-487 


27-683 


3-839 


Mean daily am't. 


1,253 


1-022 


32-923 


9-177 


1-891 


1-977 


.275 



The effect of taking in addition at times between meals a 
moderate amount of alcohol, in divided doses, is shown in the 
following table : 



* Which may be reckoned to contain from 33 to 35 per cent, of proof spirit. 



604 






ON ALCOHOL. 








Date. 


Quantity 
in cubic 
centi- 
metres. 


Specific 
gravity. 


Urea in 
grammes. 


Chloride 
of sodium 

in 
grammes. 


Sulphu- 
ric acid 

in 
grammes 


Phospho- 
ric acid 

in 
grammes 


Uric acid 

in 
grammes 


Daily quantity 

of hest French 

brandy taken 

between 

meals. 


Nov. 16 


1,180 


1-021 


30-090 


11-210 


1-954 


1-770 


Trace 


3J fid. ozs. 


" 19 


1,800 


1-013 


28-854 


9-900 


1-906 


1-800 


•258 


8 " 


" 22 


1,150. 


1-025 


32-775 


12-075 




. . . 




•71 « 


" 23 


980 


1-025 


27-930 


9-310 








71 << 


Dec. 3 


1,060 


1-023 


28-620 


9-540 


1-785 


1-696 


•339 


3 » 


" 5 


1,320 


1-019 


30-875 


9-900 


1-865 


1-980 


•330 


8 " 


" 6 


1,110 


1-021 


30-025 


9-435 


1-713 


1-665 


•299 


8 « 


u 17 


1,180 


1-020 


30-208 


9-440 


1-586 


1-652 


•343 


4 " 



It is very clear from these figures that vital metamorphosis, 
as evidenced by the amount of the principal solids of the urine, is 
diminished by thus taking more alcohol than the healthy in- 
stinct prompts. Not only are the whole mean amounts low, but 
on no day do they come up to the average. The only exceptions 
are the chloride of sodium, which is slightly increased, by what 
agency I cannot tell, and the uric acid, whose augmentation is, 
probably with justice, considered an indication of an approaching 
abnormal state. 

It may be remarked that a greater quantity of brandy than 
that recorded above spoilt the appetite and prevented the usual 
diet being taken with pleasure, thus nullifying the experiments. 



I have often given you at the bedside reasons for administer- 
ing or withholding alcohol in special cases ; but I have been 
cautious about reducing these reasons to general rules without 
going into the subject more fully than is possible in the wards. 

As you are well aware, extreme opinions may be, and have 
been, held about this indubitably powerful reagent. Dr. Brown 
(the author of the Brunonian theory) persuaded himself that it 
was a panacea for all human ills, and a direct prolonger of life ; 
but by dint of frequent experimenting, and lecturing with a bot- 
tle of brandy by his side, he soon succeeded in giving a practical 
refutation to his own words by ruining his health and shortening 
his existence. Others, again, would persuade us that it is a pure 



ON ALCOHOL. 605 

poison, whose degree of antagonism to life is in a direct ratio to 
the quantity used. I shall take for granted that your experience 
in the hospital has not made you advocates of either opinion ; 
but that you, by this time, have seen, or seemed to see, it in 
many cases saving and prolonging life, in many saving and pro- 
longing health, in many others destroying and shortening both, 
and, again, often conceded by indulgent doctors as an innocent 
luxury likely to do neither good nor harm. 

The best guide to the effects to be expected from a reagent 
on a diseased body is the intelligent observations of its effects on 
a healthy body; and I think that alcohol is no exception, but 
that a knowledge of its physiological action leads directly to its 
therapeutical application. 

The experiments of Rudolf Masing, since repeated and con- 
firmed by MM. Lallemand, Perrin, and Duroy, have taught us 
that alcohol passes through the body unaltered in chemical con- 
stitution, and does not, so far as we know, leave any of its 
substance behind. It remains in the body for some hours, and 
during that time exerts an influence for good or for evil. 

It is not strictly an " aliment ;" but if it aids the appropriation 
of aliment, it may be looked upon as an "accessory food" in 
health, and as a "medicine" in disease. 

What is the nature of the influence which it exerts ? What is 
its action upon life? It is usually defined as a " stimulus to the 
nervous system;" and so long as "stimulus" is held to mean 
only something which makes one feel comfortable, we may be 
satisfied with the explantion ; while upon the nervous system all 
experimenters, from the first patriarch downward, will agree 
that it acts. But if led by the etymology we infer that it directly 
augments the developed force of the nervous function, we shall 
fall into the error of poor Dr. Brown. 

Let us be a little more particular in our inquiries, and then I 
do not think we shall be able to trace any direct increase of 
force to alcohol, even in the smallest closes, or for the minutest 
periods of time. The sort of researches of which those detailed 
are an example, show pretty clearly that its continuous use (i. e. 
in small divided doses) does not add power to vitality, and I 



606 ON ALCOHOL. 

think we shall not fail to come to the same conclusion from ob- 
servations made upon its more immediate effects. 

In a series of experiments, conducted with another object, Dr. 
Edward Smith has recorded very minutely the sensations expe- 
rienced after brandy, by a temperate man, with a fasting 
stomach.* 

What are the first effects noticed there ? Increased life ? In- 
creased function ? No — lessened consciousness, lessened sensi- 
bility to light, to sound, and to touch. 

Then there comes a peculiar sensation of stiffness with swell- 
ing of the skin, which is noticed particularly in the upper lip 
and cheeks, evidently due to arrested sensation and motion. 
These are very unlike spurs to extra exertion. 

In a patient lately under my care the same peculiar sensation 
of stiffness, and also the objective phenomena of rigidity of skin 
without loss of sensation, were produced by the pressure of dis- 
eased bone on the fifth nerve inside the skull. f If we call this 
symptom a partial paralysis from partial obliteration of nervous 
function (to which I suppose nobody will demur), we must call 
the effects of alcohol also a partial obliteration of nervous func- 
tion, for the phenomena are strictly identical. 

Dr. Smith further records among the " early effects" of alco- 
hol a relaxation of the dartos and other muscles connected with 
the reproductive system, for which Ovid elegantly, and Shak- 
speare coarsely, blame the later and more obvious influences of 
drink. The sphincter also of the bladder was relaxed, and to 
this the observer lays the increased micturition during in- 
dulgence. 

The pulse also is quickened. At first blush you might be dis- 
posed to view this as an indication of an increase of nervous 
force. But do not be hasty. Observe with Dr. Bedford Brown 

* "Transactions of Royal Society," 1859, p. 732. 

f In this lady another facial characteristic of incipient drunkenness was 
simulated. Ordinarily the affected side had a slight diffused fixed color, the 
other being pale ; but when she blushed the healthy cheek was colored quickly 
and deeply, while the diseased one remained unchanged in hue. This is the 
same physical phenomenon which is exhibited in the half- flushed but unabashed 
front of a toper. 



ON ALCOHOL. 607 

the circulation in the cerebrum, during an operation on the 
skull, when the pulse was quickened by chloroform ; and you will 
see the heaving and bulging of the brain quieted, the surface 
becoming pale, and the haemorrhage arrested. The quickening 
of the pulse must therefore have been contemporaneous with 
diminished force of the heart's beat.* 

Again, observe that in disease those patients especially ex- 
hibit the phenomenon of quickened pulse whose hearts are most 
enfeebled. 

No — it would appear that in motion of an entirely involuntary 
character, quickness indicates diminution and not increase of 
force. 

It is unnecessary to go through the symptoms of advanced in- 
toxication by alcohol : all observations agree that large doses 
immediately, and small doses more remotely, depress the nerv- 
ous centers, and that in cases of absolute poisoning the cause 
of death is a cessation of the muscular respiratory movements. 
What I wish particularly to mark is, that the primary as well as 
the secondary action is a diminution of vitality in the nervous 
system. 

Life and warmth are so closely connected together in scientific 
as well as in popular notions that perhaps the most striking evi- 
dence of diminished vitality is the lessened capacity to generate 
heat. We have this evidence in the case of alcohol. MM. 
Dumeril and Demarquay published in 1848 their observation 
that intoxicated dogs exhibited a great loss of temperature, and 
Dr. Boecker and Dr. Hammond find the same result from even 
moderate doses of spirits. This accords with and explains the 
experience of Dr. Rae, that alcoholic drinks give no satisfaction to 
Arctic voyagers, and of Dr. Hayes (Surgeon and Commander in 
U. S. second Grinnell Expedition), that they actually lessen the 
power of resisting cold.f The "warming of the stomach" which 
tipplers speak of with delight is in fact a mere fallacy of 
insensibility to external influences. We may I think fairly come 

* " American Journal of the Medical Sciences," Oct., 1860. 
f Ibid. 1859, p. 117. 



608 ON ALCOHOL. * 

to the conclusion, that alcohol is primarily and essentially a 
lessener of the power of the nervous system.* 

How then can it be a restorative ? How can that which lowers 
one of the chief manifestations of life be a renewer of life ? 

In this way : in lowering the power of the nervous system, it 
lowers its action on destructive metamorphosis, and thus it saves 
the substance of the body. We know that the exercise of nerv- 
ous functions, bodily or mental, increases destructive metamor- 
phosis. We know, too, that when either bodily or mental action 
is in excess, there is an arrest of the constructive appropriation 
of food by the stomach. Our own personal experience, without 
the aid of Shakspeare, teaches us that passion and emotion as 
well as overstrained muscular labor put a stop to digestion and 
appetite. Well, then, anything which either sensibly or in- 
sensibly interposes between this sensible or insensible nervous 
action and the digestive viscera must tend to restore that balance 
of the two in which healthy life consists. Thus Dr. Hammond, 
having placed himself on an insufficient allowance of food, found 
his mental and bodily powers deficient — the balance was over- 
thrown. He afterward took a small quantity of alcohol with 
each meal, and then, without any increase of diet, he gained 
weight of body, and his mind was more vigorous. On the other 
hand, if he added alcohol to a full diet, the blunting of the 
mental powers was very perceptible, and there was feverishness 
of body. We cannot doubt that the essential action of the alco- 
hol was identical in both cases, but in the first the blunting of 
the nerve force was requisite for perfect life, in the second it 
was not wanted and was therefore injurious. 

The effect of small wholesome doses upon the mind is to blunt 
the sensibility to the slight half-felt corporeal pains which the 

* We may call it an " angesthetic," if it is allowed us to extend a little the 
application of the term, and to let it include all reagents which tend to inter- 
rupt the connection between the material and immaterial of our being, between 
force and visible nerve, whether our memories are conscious of the interruption 
or not. It is only when it is taken in considerable doses that our direct feelings 
note the anassthetic action of alcohol. Its action on the involuntary nervous 
system, more important in a physiological point of view, is anterior to that, but 
can be traced only by inference. 



ON ALCOHOL. 609 

want of balance had produced. It removes the chains of the 
corruptible body from the soul. Hence a freedom and bright- 
ening of the intellect. But it is only the moderate man that 
can enjoy this luxury; the attempt to drown a care too tall for 
a shallow bowl, or to soothe a pain too sharp to be forgotten, 
induces an excess. Then the scale is inclined too much the 
other way ; the influence of the nervous system on the body is 
overblunted, and the just degree of its action requisite to perfect 
health is arrested. 

In truth, this balance is not easy to adjust. And therefore it 
is lucky for us that alcohol passes so freely out of the body, as 
Dr. Percy, Mr. Masing, and the French physiologists who have 
repeated their experiments have shown to be the case. It is 
lucky for us also that any slight harm it may have done during 
its sojourn is set right by a reaction of increased metamorphosis 
or evacuation, of which an example has been given in the ex- 
periments detailed at the beginning of this lecture. 

Thus do I interpret the effects of alcohol ; and taking this 
interpretation as a basis, I would deduce therefrom the following 
clinical rules for its administration: 

I. Give alcohol whenever you find the nervous system is ex- 
hausting itself and the body by an activity in excess of the other 
bodily functions. 

Examples : 

In delirious fever, especially in typh-fever. Here the high 
specific gravity of the urine is a warrant to you of the great 
amount of destructive metamorphosis going on, and the failing 
strength shows how low the constructive life is. Continue the 
alcohol as long as the tongue is dry, and the mind raves instead 
of sleeping, and the hands tremble. 

In pneumonia, in surgical injuries, in erysipelas, &c, under 
the same regulations. Here, however, our path is not so clear 
nor so well- enlightened by physiolog}' ; we must feel our way by 
actual observation of the effects produced on the patient under 
our eye. 

The power of resistance to some poisons, such as malaria, 
seems increased by alcohol. Thus aguish and neuralgic cases, 



610 ON ALCOHOL. 

in their Protean forms, bear well and are benefited by it in very 
considerable quantities. Strangely enough, these patients on 
recovery cannot stand it, and usually of their own accord leave 
off the habit of taking it. So that we need not fear that we 
shall make them tipplers by administering the remedy. 

After violent shocks produced by mental emotion, or extreme 
bodily labor. It may be doubted whether the prejudice felt 
against serving out spirits to soldiers or sailors before a battle 
is justifiable ; the courage or apparent strength given .may be 
tinsel, but the power of resistance to wounds, mental and bodily, 
is something real. 

Where the patient has been accustomed to excess. It will 
not do to let the body have to endure the natural reaction and 
the disease at the same time. The reaction must be postponed 
to a more convenient opportunity, when the body is ready 
for it. 

II. Give it, increase it, leave it off under the guidance of the 
appetite for food. As long as a sick person takes and digests 
food better with alcohol than without, so long it is doing good. 
Beyond that we have no evidence. 

III. When the marked feature of the disease consists in re- 
tention of effete matters which ought to be discharged, abstain 
from the use of alcohol altogether. 

Examples: 

In Uraemia I have always found any effects which could be 
traced to alcohol to be of an injurious character ; under its 
employment the giddiness, the blunted intellect, the faintings, 
the tendency to coma, all increase, the urine sometimes becomes 
more scanty, always of lighter specific gravity ; and I cannot 
say that even the dropsy, for which the alcohol is most usually 
administered, is often benefited. 

Jaundice also seems to be aggravated by alcohol. 

The uric acid diathesis also presents an objection to the use 
of alcohol ; but there are exceptional complicated cases which 
appear to receive benefit from occasional doses. 

IV. Divide the daily allowance into two or three doses only, 
giving enough at once to produce a decided effect. The action 



ON ALCOHOL. 61 L 

of frequent small divided drams is illustrated by the experi- 
ments I have detailed — it is to produce the greatest amount of 
harm of which the alcohol is capable, combined with the least 
amount of good. 

In fever I usually order three doses a day, and find even that 
division not always advisable, and that the patients do better 
with two larger doses. 

The shape in which alcohol is administered is in many cases 
not a matter of choice. The mighty force of the purse-strings 
often restricts us to the coarsest compounds. New whisky and 
gin and British brandy are better than nothing, but let us not 
forget that they contain a very hurtful, nay almost poisonous in- 
gredient, fusel oil, which is abundant in direct proportion to 
the youth and low price of the article. Age changes this into 
more wholesome as well as more agreeable ethers. Any of the 
full-bodied wines are better for acute cases than spirits. Port 
perhaps exhibits in its commoner varieties more of the good 
qualities that a wine should have than the produce of other 
grapes. I mean to say that second and third-rate port, or even 
sham port, is a wholesomer beverage than second and third-rate 
and sham articles with other names. But if the expense is no 
object, thoroughly good champagne exhilarates more, is easier 
digested, and does the good without the harm better than any 
of its rivals. Of course a high price must be paid for a genuine 
specimen of a wine so restricted in quantity. 



LECTURE LI. 
ON BLOOD-LETTING. 

Part I. — The power of renewal in the animal body exemplified 
by the quick restoration of normal blood in an ansemic girl — 
Application of these facts to the artificial anaemia induced 
by blood-letting — The necessary conditions for the repair of 
ansemia — Starving and bleeding at the same time bad practice 
— Reasons for bleeding — 'Fallacies of the ancients. 

Part II. — Cases in which loss of blood is beneficial — In some 
cases of apoplexy — In pneumonia — In the congestions of 
typh-fever — In serous inflammations, in pleurisy, pericardi- 
tis, and peritonitis — In renal congestion and hsematuria — 
In paralysis of the circulating organs from over distention 
— In chronic diseases of the skin — Conclusion. 

{Clinical, St. Marys, November 29, 1861.) 

A fortnight ago I lectured about an anaemic patient.* She 
was then showing a title to be no longer so called; and now she 
most certainly may claim exemption, having fairly won our faith 
in the statement that her natural hue is rosy. She is leaving 
the hospital to-day with enough haematine to color the blood 
throughout her body very sufficiently. 

Let us take stock of what we may learn from her agreeable 
change of looks. 

What amount of manufacturing industry does this new store 
of haematine prove ? Let us do a sum. She weighs 8 stone, or 
1792 ounces : of this weight f-ths, or 512 ounces, is blood ; and 

* See previous lecture on Anasmia. Lecture XXVII, p. 3 61. 



ON BLOOD-LETTING. 613 

of this blood yV^o, or 60 ounces, should be reel disks. Now the 
careful analyses of MM. Andral and Gavarret show that in cases 
of anaemia of a marked character (as this was), we may expect 
at least three-quarters of the haematine to be wanting ; so that 
when she came into our wards it may be fairly taken for granted 
that she did not possess above 15 ounces ; and now I think with 
equal fairness her stock may be reckoned to have got up to 45 
ounces, which is to allow that she still wants a quarter of her 
perfect health. By this reckoning she must have made 20 
ounces of blood-disks, — so much of the most important organic 
constituent of upwards of 150 ounces of blood, — in a month ! 

Mark the vigor of renewal with which the human body is 
dowered. Learn from this to have faith in its power, and to 
trust in it, though prospects may look untoward. Learn 
especially the curability of even the most unfavorable specimen 
of anaemia. And learn too not only its curability when it is a 
disease which has come of its own accord, but also the facility 
of repairing artificial loss of blood when it is employed as a 
remedy. 

I hope you all by this time clearly understand that physio- 
logically speaking all departures from full health are diseases. 
The artificial states which many of our remedies produce, some- 
times even as a means of doing the patient good, but more often 
as an incident unavoidable and lamented by us, are as much 
diseases as any of those on the roll of the Registrar-General. 
Diarrhoea is as much diarrhoea, whether it is caused by Epsom 
salts, by a felonious poisoner, or by a poisonous malaria. So 
anaemia is as much anaemia when it follows our lancet and our 
leeches, as when it arises we cannot tell how, and comes to us 
for advice. It must be equally thought of, guarded against, and 
cured, in one case as the other. But what I particularly wish 
to insist on here is that it is as easily thought of, guarded 
against, and cured in one case as the other. 

It has been the fashion lately among certain declaimers to 
paint the physician who draws a few ounces of blood from the 
arm, or cups or leeches a sick man, as a sanguinary villain, who 
necessarily ex vi termini takes away the life, or that which he 



£14 ON BLOOD-LETTINU 

cannot replace. Not only novelists, pill-dealers, and quacks 
have raised this outcry, but it has been joined in by some whose 
knowledge of physiology ought to have taught them the fallacy 
of the popular notion and the argument by which to refute it. 
You will clearly perceive from the calculations through which I 
have taken you that by proper management no loss is easier re- 
paired ; and consequently that if it only saves a patient two or 
three nights' sleeplessness and pain, the price of a venesection 
is well paid ; and still more, if it contributes in the remotest 
degree to free him from danger, it is blood well spent. 

Nevertheless, note this, that if the loss is to be repaired, the 
means of repair must be given. When I bleed, you will observe 
that I take down the diet card and suit it to the circumstances, 
being very careful that the patient has the power to reinvest the 
capital drawn out. I supply with one hand what I am taking 
away with the other. I begin to try and cure the anaemia, which 
I feel myself called upon to produce, at the same moment that I 
am producing it. "Blowing hot and cold," you will say. Pre- 
cisely so — that is what I intend. I blow cold with my bleeding, 
not for the sake of blowing cold, but because it is the inevitable 
result of the remedy. I blow cold not in order to induce anaemia, 
but for other quite different purposes, which I think are worth 
the cost. And I blow hot to make up as well as I can for the 
evil I am going to do, on the principle — 

" Facere necesse est sumptum, qui quserit lucrum." 

I am sure that the sad effects of the too zealous practice of 
our fathers, which with justice have been cast in the teeth of the 
medical profession, were due quite as much to the starvation as 
to the bleeding. I have a most lively and painful recollection 
of seeing, when I was a student in Paris, M. Chomel and others 
treating pneumonia. I could not at first understand why in 
France so much more marked and more hurtful effects were pro- 
duced by venesection than in England. At that period we had at 
home ample opportunities of seeing it practiced; but 1 never wit- 
nessed such prostration follow at St. George's as I did at the 
Hotel Dieu. I was puzzled for a week or two, till at last I 



ON BLOOD-LETTING. 615 

noticed that the order for " saignee " was accompanied by " diete 
absolue" I almost doubted my knowledge of French, and was 
obliged to ask of the by-standers before I could believe that this 
meant an utter deprivation of all food ! Here was an immediate 
explanation of the seeming toughness of my countrymen; for 
never in our worst days did we carry the Sangrado practice so 
far as that. Our teachers did not give food enough, but they 
never bade it to be willfully kept beyond their patient's reach. 

The bad practice of starving and bleeding at the same time 
took its rise from the erroneous doctrine of antagonism. Accord- 
ing to this theory disease is an enemy to be overcome — A Disease 
with a proper name and a capital letter to it, like a living con- 
crete creature — a something to be combated by a something 
which is as opposite to it as possible. Bleeding was found by 
experience to be useful in certain morbid states ; it was therefore 
held to be useful in virtue of possessing qualities opposite to these 
morbid states. Anaemia and depression of life are the most con- 
stant effects of bleeding; therefore anaemia and depression, it was 
argued, are the benefactors to be sought for, and whatever aids 
blood-letting in producing anaemia and depression is a good com- 
panion to it. Of course starvation w T as the first agent thought 
of, adopted in all its integrity by the logical French, and with 
more hesitation by our countrymen, who fortunately do not carry 
out all arguments to their apparent conclusion, and therefore are 
often right without knowing why. The abuse has brought about 
a reaction ; and that treatment which was considered at one time 
so sovereign that its gravest faults were viewed as virtues, now 
runs a risk of being denied all virtue, because of faults capable 
of being compensated for. 

Against this I feel bound to raise my voice. It is time now 
to have done with the reactions for and against letting blood, 
which have been going on throughout the period of the Christian 
era;* the wave, which has swelled backward and forward to a 

* A short sketch of the reaction in favor of blood-letting started by Galen, is 
given by the author in the " Medico-Chirurgical Quarterly Review" for October, 
1858. The shrewd chatty Greek hits hard at his opponents, and seems to have 
had a single-handed fight with all the world of fashion against him, and yet came 



616 ON BLOOD-LETTING. 

dangerous height, ought to settle down into a steady stream. 
We ought to know clearly why we bleed, and then we shall know 
when to bleed. 

The question seems to me one to be answered by hydrostatics 
rather than by physiology. The most important early effect of 
external injurious action on the tissues is that the blood-vessels 
lose their tone and become dilated, the " congestive stage of in- 
flammation" occurs. At this conjuncture the more pressure of 
fluid there is inside the more will their elasticity be impeded, and 
the more dilated must they become. Taking blood from them is 
like emptying the urinary bladder with a catheter when it is 
paralyzed by its retained contents; and the more locally the 
remedy can be applied, the more like it is to that generally ap- 
proved surgical operation. Dropping the burden which weighs 
down their life, the vessels are enabled to go again to their work 
of regulating the stream of the circulation. So that from this 
point of view, and so far, the treatment is directly restorative 
and reconstructive. Blood-letting is a cure of local congestion, 
and to the local symptoms it may be expected to be beneficial. 

The fault of our forefathers was that they went beyond this. 
They pictured to themselves a condition of universal plethora, 
or general excess in quantity of blood throughout the blood-ves- 
sels — a condition which every observant and practical physician 
now sees can have no existence in nature.* Where experiment- 
out victorious in the end. It is satisfactory to find him free from the vulgar notion 
that human nature and its diseases are liable to changes of type, delivered from 
the superstition that 

JEtas parentum, pejor avis, tulit 

Nos nequiores, mox daturos 
Progeniem vitiosiorem. 

He never suggests that any one generation could stand bleeding either better or 
worse than their ancestors; but he notices a fact, which probably explains a 
good many of the revolutions of public opinion, namely, that some races are 
much more affected by it than others — the Celtic, for example, more than the 
Latin. It would be interesting to trace historically how the prominence of one 
or other nationality as teachers of medicine has altered the prevailing practice. 
* By u plethoric" old writers do not mean "fat," but a state in which too 
much blood and flesh were supposed to be made by too much nutriment being 
absorbed. It is the latter or primary meaning of the word which I refer to in 
the text. 



ON BLOOD-LETTING. 617 

ally they saw good results follow the emptying of the blood-ves- 
sels, they pronounced the special disease before them to be a 
proof of this plethora, and hence inferred that the loss of blood 
was directly beneficial to the system at large by restraining an 
excess of "violence of life." 

We know now that a destructive agency keeps step with the 
reconstructive one — that our gain entails a loss. By blood-let- 
ting is brought about, temporarily or permanently, first a decrease 
in those red blood-disks which are the characteristic of health, 
and then an increased proportion of fibrin which marks disease. 
So that an injury is done to the mass of the body for the sake 
of a part — a temporary injury for the sake of a permanent 
benefit. 

The questions, then, which we have to decide in each several 
case are — first, whether we can by our art certainly repair the 
artificial injury; secondly, whether the part to be relieved is of 
sufficient importance to the whole to justify the sacrifice; and 
thirdly, what is the least amount of sacrifice that will be of use. 

As to the first question, the daily occurring evidence of such 
cases as those of which one has formed the text of to-day's hints, 
is surely enough to give us faith in the means of renewal at our 
command. As to the second and third, more details are required 
than we have time for to-day, and I must wait for another oppor- 
tunity of enlarging upon them. 

Part II.— {Clinical, St. Marys, March 5, 1864.) 

Taking for granted that certain evils attend a loss of blood, 
while certain advantages may also be derived from it, the ques- 
tion is, when does the prospect of advantage overbalance the risk 
of evil? It is my purpose, to-day, to set before you a list of cer- 
tain instances in which it appears to me to do so. 

1. Some cases of apoplexy. 

The cause of apoplexy is obliteration of the cerebral nervous 
functions. And this may take place in two ways : 

1. By actual destruction of the nervous tissue. 

2. By impeded circulation of blood through the brain. 

40 



618 ON BLOOD-LETTING. 

To an inward wound of the nervous tissue, causing actual de- 
struction, whether it take place by violence, by the pressure of 
a clot of blood or of a tumor, or by the more usual case of 
atrophic softening, blood-letting can afford no assistance. The 
immediate effect of the lesion is bad, and the more remote effects 
worse. 

But to the impeded circulation a cure may be surely applied. 
When from the filling up of the cerebral veins and capillaries 
with venous blood, black, effete, and useless, room cannot be 
found for the arterial quickener — when life is stagnant, so to 
speak, from the stagnation of its river of supply — then you may 
restore the stream by the rough and ready means of an artificial 
outlet. 

When the lips and tongue are tinted blue with venous blood ; 
when the pulse is filled and sluggish; when the heart, either 
from chronic lesion or from repletion, has hardly room to strike 
the ribs ; then you may withdraw blood with advantage, for you 
may relieve the congestion which is obstructing the sanguifica- 
tion of the brain. 

When the lips are pale or naturally colored; when the pulse 
is free or empty, striking the finger with a high sharp stroke; 
when the heart beats freely, even if it should murmur in your 
ear that its valves are imperfect ; then the lancet and the leech 
are useless, nay, hazardous. 

The indications afforded by the general symptoms are less 
positive. 

General convulsions may arise from congestion, as often hap- 
pens in the apoplexy from drowning or hanging, and are not by 
any means a certain contraindication, as is sometimes stated. It 
is, however, as well not to bleed during the paroxysms. But I 
think that where the convulsion is local, where it occurs in one 
or two limbs otherwise paralyzed, that then it usually arises from 
local lesion of the nerve substance, and is an argument against 
drawing blood. 

When the apoplexy has, in a previously healthy person, come 
on gradually, beginning with stupidity, giddiness, and headache 
without local paralysis, and passing, in times varying from an 



ON BLOOD LETTING. 619 

hour to a day, into complete loss of sense and motion ; when the 
sphincters slowly become relaxed, and continue so; when the 
patient may by a violent effort be a little roused, lapsing again 
into unconsciousness ; then it is not uncommon to find the symp- 
toms depend on congestion and relievable by bleeding. When it 
has come on suddenly, a local paralysis being contemporaneous 
with or preceding the clouding over of the mind; when the 
sphincters hold their own, or are only intermittent in relaxa- 
tion ; when the senses which have been suddenly lost are either 
completely lost, or completely recovered; then you are wiser 
to abstain, for you probably have to do with broken nervous 
tissue. 

This is about as much as you will have time to think over 
with your patient before you. 

It has been argued by Drs. Munro, Kellie, Abercrombie, and 
others that, the brain being inclosed in an unyielding case, and 
thus excluded from atmospheric pressure, the quantity of blood 
in it cannot vary, and therefore that detraction of blood from the 
whole bulk of the fluid in the body can make no impression on it. 
But the experiments of Dr. Burrows, exhibited before the Col- 
lege of Physicians, have shown that at least the color of the 
brain and the quantity of blood in its veins may be much af- 
fected by external circumstances; and that is the point in ques- 
tion; it is the maldistribution of the blood, the venosity in the 
brain, that we want to restore to its normal condition, and I feel 
sure that bleeding may temporarily contribute to that result in 
the special cases of which I have spoken. 

2. In some cases of pneumonia. 
• The reason for blood-letting in pneumonia is shortly stated 
by the late President of the College of Physicians, when he says, 
"Although pneumonia is not cured by blood-letting, and may be 
rendered fatal by excess of it, yet a moderate loss of blood early 
in the disease has sometimes the power of determining favorably 
both its type and its duration."* That is to say, that though 
the pneumonia is not cured by the blood-letting, the patient 
sometimes is. Observe the experiments shown us in the great 

* Dr. Mayo in "British Medical Journal," May 6, 1863. 



620 ON BLOOD-LETTING. 

lecture-theater of nature. You see that often great relief is ex- 
perienced when blood is expectorated in the early stages of the 
disease, that the inflammation ceases to spread over the tissue of 
the lung as soon as the mucus is stained with red. Get the start 
of this by prevenient bleeding or cupping or leeches, when the 
other circumstances on which I enlarge in lectures on special 
cases of pneumonia allow it. It will diminish the dyspnoea, the 
oppression and the pain. And you will be quite safe as long as 
you will bear in mind that you are doing a certain harm at the 
same time as a certain good, and anticipate the harm by proper 
nutrition, and sustaining the strength of the body. 

Observe also the experiments exhibited by nature in localizing 
the blood-letting. You cannot, as she does, let blood from the 
bronchial and pulmonic vessels, but you can make the nearest 
approach in your power by taking it from the exterior of the 
chest-walls through cupping-glasses or leeches. 

3. In the typhous congestive inflammations of the lungs and 
bowels taking blood by leeches or cupping from the nearest ex- 
ternal surface is often judicious. The relief is usually very rapid 
and immediate, and the risk run from a small loss of blood very 
little. The fluid you take away, though called by the common 
name of blood, is not the same as an equal quantity circulating 
in the veins of a healthy man. It is more or less poisoned, more 
or less useless for the purposes of life, and the loss is far from 
being in a direct ratio to the amount taken. It is more important 
that the patient should regain the use of his bowels, or of a con- 
gested lung, than that he should keep such imperfect stuiF cir- 
culating or stagnating in his blood-vessels. Of this I have 
spoken at length in former lectures. 

4. The same remarks will apply to acute dysentery, in which, 
indeed, an indication of treatment is afforded by the natural 
course itself of the disease. The worst cases are those in which 
there is no loss of blood by stool, and, alarming as it is, san- 
guineous purging often saves the life of the sick. 

5. In inflammations of serous membranes, such as pleurisy, 
pericarditis, and peritonitis, a great part of the danger arises 
from the quickness with which the continuous parts of the same 



ON BLOOD-LETTING. 621 

tissue yield to the destructive influences of neighborhood. This 
quickness is certainly checked by the direct counteraction which 
loss of blood affords to the congestive stage of inflammation. 
The local capillaries show their partial deficiency of life in loss 
of elasticity, in dilatation, and in being overfilled with blood. 
Leech the neighborhood, and you temporarily empty them, and 
you postpone, at least for a time, the coming inflammation ; you 
gain time; and time is no mean gain, for it gives the smitten 
body a period of rest in which it can store up force to effect a 
cure. But it is only time that you gain, for when the first stage 
of inflammation is over, when "its work is done, its path of ruin 
past," then your detraction of blood is a robbery. 

As to locality, the nearer you can approach to the part in- 
flamed the better; for the action is hydrostatic, and mechanical 
forces lose by distance. In peritonitis put your leeches on the 
painful side of the belly — that is, where congestion is going on, 
for after effusion of fibrin or pus, pain ceases at the point of effu- 
sion. In pericarditis, apply them close together at the level of 
the mammae, or where the apex of the heart beats, according to 
where the chief pain on pressure is found to be. In women 
with full bosoms, shun the mammary gland ; not because you 
will hurt it, but because it removes your leeches too far off. In 
pleurisy, leech as near the pain as may be; take care, however, 
to keep above the level of the diaphragm; even although the 
stitch, as often happens in diaphragmatic pleurisy, should be 
felt by misplaced sensibility below the ribs. In this case espe- 
cially you should mark for the nurse the spot where the leeches 
are to be put on, for you must remember that she is not an anat- 
omist, and has not learned where the pleura ends and begins ; 
she is likely, therefore, to be led into error by the faulty sensa- 
tions of the patient. 

The amount of blood-letting must be proportioned to the risk 
run by the spread of the inflammation. In peritonitis this is 
very great and immediate: leech, therefore, freely, and cover 
the congested spot with the remedy. Two dozen leeches even 
are not too many in pressing cases. But do not use so many in 
case of repetition. Then cover the place (having first stopped 



622 ON BLOOD-LETTING. 

up the bleeding bites with dry lint) with a linseed poultice, or 
Markwick's spongio-piline; keep the patient quite still, and pro- 
cure sleep with opium. Thus you will make the best use of the 
time gained. 

Follow the same rules in pericarditis; only you will not want 
so many leeches, as there is less space to be covered; six, eight, 
or at most ten, will be quite enough, according to the size and 
sex of the patient, and the correspondent size of the exposed 
piece of pericardium. Moreover, in pericarditis you are more 
likely to require a second application, as you cannot procure 
such perfect rest to the heart as to the peritoneal viscera. Poul- 
tices and opium, however, are well spent here. 

Pleurisy, unaccompanied by pneumonia or catarrh, is not such 
a pressing complaint. Half a dozen leeches and a poultice are 
usually quite enough to manage it. 

6. Congestion of the kidneys is apt to produce a continuous 
drain of blood by the urine ; and from the great weakness thus 
arising, it seems not unlikely that the material thus lost is arterial 
and vitally important. Moreover, protracted congestion of the 
kidneys often ends in the permanent degeneration of Bright's 
disease — a result most unhappy. When, therefore, after scarla- 
tina, exposure to cold, blows, or other causes, I find visible 
hematuria, I almost always cup the patient on the loins. I can- 
not say that the practice is invariably successful in effecting its 
intention ; for the loins are some way off the kidneys, and the 
force of the remedy is much diluted by the time it influences the 
point of attack. But it succeeds often enough in stopping the 
hematuria to make it worth while to lose eight or ten ounces of 
blood in the trial. 

7. The same considerations may sometimes induce us to treat 
by emission of blood a congestion unimportant in itself, but im- 
portant from its neighborhood ; such as swelling of the tongue 
or tonsils, which we fear might suddenly compress the glottis. 

8. When the heart is temporarily paralyzed by overdistention, 
either completely, so as to produce apparent death, or partially, 
so as to produce what is technically known as a "very oppressed 
pulse," joined with anxiety and dyspnoea, then bleeding and still 



ON BLOOD-LETTING. 623 

more cupping the cardiac region is often of signal service. The 
relief is of course mechanical ; the dormant excitability of the 
heart is roused by the artificial motion communicated to the cir- 
culation ; and perhaps also the sensitiveness of the nervous 
system is heightened by the absence of blood, just as tonic mus- 
cular contractions are induced by excessive haemorrhage, by 
starvation, &c* 

9. Blood-letting may sometimes be employed in chronic skin 
diseases, to render more efficacious the action of certain specific 
remedies for certain specific forms. Thus in lepra, and in pso- 
riasis, I have several times arrived at a point which arsenic and 
sulphur did no further good, even in doses larger than are usually 
considered safe. After bleeding the patient, a smaller dose pro- 
duced an immediate effect and a rapid renewal of healthy skin. 
I have remarked the same fact in a nearly equal degree, as 
respects the action of alkalies in eczema. Last week I called 
your attention in the admission-room to the arms and legs of a 
gardener, as exhibiting quite a typical case of eczema in pic- 
turesque distinctness : I had him bled to six ounces, gave him 
a bran bath and only three doses of liquor potassse, and next cUy 
when we saw him in bed he was so much better that I was obliged 
to apologize to you for the departure of most of the characteristics 
of the disease. And last year in a case of extensive lichen no 
good at all was done by emollient baths of bran and linseed, till 
I bled the patient, and then these simple agents were sufficient 
to effect a cure. After these bleedings, if beneficial, no weakness 
is felt. 



These are examples of the principal circumstances under which 
you will find me in my practice think it advisable to take blood. 
You will see that they generally agree in this, that there is a 
want of due circulation, a true deficiency in that important func- 
tion of the vascular system. The flow of blood restores this cir- 
culation, for though the blood flows out of, instead of flowing 

* See M. Ckossat's observations, quoted in Lect. II, pp. 45-49 



624 ON BLOOD-LETTING*. 

through the vessels, it is a nearer representation of the living 
act than the previous stagnation. In all the concerns of organic 
life, as of social life, anything is better than stagnation. 

The physiological reasons for localizing as far as possible our 
blood-letting are exceedingly well put by Dr. Young. " The 
eifect of venesection must be not only more rapidly, but also 
more powerfully felt in a neighboring than in a distant part ; and 
although the mean or permanent tension of the vessels of any 
part must be the same, from whatever vein the blood may have 
been drawn, provided that they undergo no local alteration, yet 
the temporary, change, produced by opening a vein in their 
neighborhood, may have relieved them so effectually from an ex- 
cess of pressure, as to allow them to recover their natural tone, 
which they could not have done without such a partial exhaustion 
of their neighboring vessels."* 

The history of opinions on the subject of blood-letting shows 
us four sects or parties, each one of which has at various times 
outweighed its rivals in number of adherents. First, the fol- 
lowers and predecessors (for " vixere fortes ante Agamemnona ,s ) 
of Hippocrates, who sometimes bled, but always fed, their pa- 
tients. Second, the disciples of Erasistratus, who denounced 
bleeding as robbery, and prescribed in its place a complete star- 
vation for several days — ScdrpiTog hatjia. Third, the French prac- 
titioners of the two last centuries, immortalized but not checked 
by the satire of Moliere and Le Sage, who both bled and starved 
at once. Fourth, the followers of Brown, who replaced bleeding 
by alcohol.f 

From what has been said it will be seen that I should find 
myself a member of the first-named sect, if the unhappy mania 
of party spirit were again to afflict our profession as it has done 
of old. And were hero-worship again to become one of our fail- 
ings, I should probably select as the Bible of my medical faith 

* Croonian Lectures in " Philosophical Transactions of Royal Society," 1809. 

f I do not here include as a practical school "La Medecine Expectante,' 
which objects to bleeding just so much and no more as it objects to everything 
else. In an ignorant man this is merely unwarranted skepticism, in a wise man 
it is a philosophical experiment. Neither can suppose themselves engaged in 
an act of cure. 



ON BLOOD-LETTING. fi25 

Hippocrates' " Regimen of Acute Diseases." For if it might be 
allowed, out of consideration for the differences between Athens 
and London, to substitute beef-tea for gruel, there is very little 
in that capital course of lectures which does not accord with the 
daily practice of those I think wisest among us in the present 
day. 

But how different are the grounds on which our practice is 
based ! The Greek had merely the limited guidance of empirical 
observation, aided in his individual instance by a remarkably 
shrewd instinctive feeling of what the normal progress of disease 
is, and how far it is modified by remedies. We have a crowd of 
anatomical and physiological facts, which may be brought to bear 
on the subject, and which may keep us from wasting our time in 
unfruitful experiments ; and we have spread open before us in 
our public hospitals a wide volume for those -who will read it 
aright, illustrating the natural history of disease and its conse- 
quences. It is not necessary for any one of us to be an Hippo- 
crates for us to cure disease much more safely than he was able 
to do, and probably in no remedy is this so clearly shown as in 
the application of blood-letting. 



LECTURE LI I. 

ANSWERS TO OBJECTIONS AGAINST THE THEORY AND 
PRACTICE OF CURE BY RENEWAL OF LIFE. 

[Lectori benevolo. Not delivered viva voce. ) 

He that for the first time happens to hear it made an aphorism 
of therapeutics (as it has been in the preceding lectures) that 
morbid phenomena are always evidence of deficient vitality, may 
not unreasonably find a stumbling-block in the following obser- 
vations which a thoughtful student of nature will not fail to make 
on the patients before him : 

First. Morbid excretions and secretions are often more 
copious than natural. 

Second. Morbid solid products may add to the size of the 
parts they are attached to. 

Third. Morbid muscular motions may be excessive. 

Fourth. Morbid mental phenomena may be apparently 
excessive. 

Fifth. Morbid temperature is often higher than the normal 
average. 

Sixth. Sensibility is sometimes increased by disease. 

I will answer these objections in detail. 

First objection. — The copiousness of morbid excreta will be 
observed to depend not on the addition to them *of such organ- 
ized products as are useful in assisting vital processes, but of 
such as are the result of the physical decomposition of the body, 
or of its deficient resistance to external cosmical agents. In 
diarrhoea there is not an extra formation of pepsin or other di- 
gestive juices in the alimentary canal, but a flood of liquid re- 



ANSWERS TO OBJECTIONS. 627 

suiting from the diminished endosmosis compared with exosmosis 
— just as you have a flow of water down the waste-pipe of a 
cistern when you do not use so much in the house as usual. 
Thus, also, medicines and diseases which increase the amount 
of hepatic secretion found in the stools, do so by poisoning 
either the secretion itself or the intestinal absorbents ; so that 
not the quantity made but the quantity wasted is in excess. 
Waste is no proof of life. Again, in urine abnormally aug- 
mented there is found no excess of its essential part, urea, but 
in almost all cases a deficiency ; those instances of apparent 
excess formerly classed as azoturia, baruria, &c. really resolving 
themselves into irregular retention and consequently irregular 
evacuation. The urea is first retained, then thrown out for two 
days in one. Again, in the bronchi, how can we call excessive 
mucus an excess of life, when even popular observation takes its 
superabundance (the "death rattle") as a proof of immiment 
death ? It is not the business of healthy mucous membranes to 
be covered with mucus at all, and when they are so it is a sign 
of deficient life, local or general. Mucous globules consist of 
young epithelium, or rather of matter which ought to have been 
epithelium, which ought to have lived remaining adherent to the 
basement membrane, and performed the local duties, but which 
has miscarried and become a tenacious fluid instead of a con- 
tinuous solid.* 

Second objection,— viz. That morbid products may add to 
the size of the parts they are attached to. 

The fact that diseased parts are often increased in solid bulk 
is of serious import, and suggests two questions both of very 
practical bearing : 

Firstly, does augmented bulk imply augmented general life in 
the individual ? 

Secondly, does it imply augmented local life in the part 
affected ? 

To the first question a sufficient answer may be found, which 
a few visits with the eyes open to either medical or surgical 
wards of a hospital may show to be true ; namely, that it is not 

* See Lectures III, IV, V. 



628 ANSWERS TO OBJECTIONS. 

the burly, full-pulsed, red-blooded man of large appetite and 
great muscular power that is most liable to exhibit a specimen 
of solid morbid matter, but the anaemic starveling, quivering at 
a breeze or a blow. 

In what corpse do you find the largest weight of fibrin thrown 
out in the peritoneum in the shortest possible time ? In one 
dead of puerperal fever — that is, in the weaker sex at the period 
of its greatest weakness. 

In whom is rheumatic fever most likely to cause pericarditis, 
with its great masses of morbid matter ? In the young over-, 
grown person, especially if a female, and more especially if an 
overworked, underfed needlewoman or maid-of-all-work. 

In whose heart do the consequences of this pericarditis most 
readily induce hypertrophy ? Not in the well-fed and well- 
clothed idle or professional man or woman; but at the same 
time of weakness, in the same weakly sex, and under the same 
weakening circumstances as the original disease came on. 

Cancers and other tumors again, are found most often and of 
quickest growth in the least lively bodies, in the least lively 
parts, and in those which are half killed by wounds, injuries, or 
previous disease. 

It is perhaps not impossible that, while the general vitality of 
the individual is lessened, some part might exhibit an extra 
amount. But morbid processes are not evidences of it : they 
rather resemble developments of a lower form of life : their pro- 
ducts, though abundant, are less vital than the normal growth 
whose place they take; their existence is temporary, and "they 
are not capable of becoming permanent constituents of the body, 
or of lasting as long as the individual."* Examine a patient 
with thickened heart during life, and the pulse does not strike 
your finger vigorously, the apex of the organ does not beat 
sharply against the ribs ; indeed, the thicker it ' gets, the less 
powerful is both pulse and beat, and the less actively does the 
blood course through the vessels. Dissect it after death, and 
you will seldom fail to find a pale tissue with microscopical 
evidences of commencing fatty degeneration. Still more evi- 

* Virchow's "Cellular Pathology," p. 456. 



ANSWERS TO OBJECTIONS. 629 

dent is the same degenerative tendency in cancer. The tissue 
of malignant tumors, directly it ceases to grow rapidly, begins 
to decay, to shrink, and to be converted into fat. It is hard to 
imagine local strength or local excess of life producing such a 
weakling crop. 

In cancer, truly, there is a continuous reproduction of new 
foci of growth, a new progeny of prolific cells, which certainly 
does look like an extension of local life over a larger space, if 
not the production of fresh local life. But then we should reflect 
that the highest and most vital function of nutritive growth is 
the retention of the form of the body or its separate parts ; 
that in morbid augmentations of size this is lost: the controlling 
power is absent, and the more so the more morbid and the larger 
the augmentation is. The formlessness of cancerous and of the 
so-called hypertrophic tissues seems to refer them to a lower 
grade of organic life than normal growth. 

Third objection. — That morbid muscular motions are often 
excessive. 

It is the function of muscular tissue to contract, and there- 
fore when it contracts oftenest and most it might at the first 
blush seem to be fullest of life. But on the other hand, its 
function is to contract in obedience to antecedent animal acts ; 
the voluntary muscles in obedience to the will, the involuntary 
in obedience to other demands. And moreover, it does not 
seem certain that relaxation is not an active state as well as 
contraction, for reflex muscular actions, such as winking, yawn- 
ing, sneezing, laughing, &c, can often be prevented by an effort 
of the will keeping the muscles relaxed. The highest develop- 
ment of life is the fullest submission of the muscle to its natural 
master. 

Observe, in excessive hemorrhage, which I suppose nobody 
will call an exaltation of vitality, there is spasm, convulsion, 
sometimes epilepsy. In diseases universally acknowledged to 
be debilitating you find that irregular constant motion called 
subsultus tendinum, and the nearer death, the more marked it 
is. When the limbs are wearied by violent exercise, they start 
and quiver, and cramps keep us awake after a hard day's walk- 



630 ANSWERS TO OBJECTIONS. 

ing. The weaker the will, the more frequent and more violent 
are hysteric paroxysms. In short, the rule appears to be, that 
as the debility is greater, the more frequent and more uncon- 
trollable are the muscular contractions, and the easier are they 
excited. 

Fourth objection. — That morbid mental phenomena may be 
excessive. If we examine carefully the minds of those in whom 
one or other mental faculty appears excessive, we find that the 
apparent excess is due to the deficiency of another faculty, 
which in the normal state balanced or controlled it. Thus, for 
instance, the drawings and handwriting of incipient lunatics 
sometimes exhibit a delicacy and minuteness almost super- 
natural. This appears to arise from want of imagination and 
taste. The wonderful memory for little things which these 
people exhibit is seemingly dependent on the emptiness of their 
minds of other sensations. That intellect, judgment, poetical or 
artistic power are ever really developed by insanity, is merely a 
popular delusion. 

Fifth objection. — Life and warmth are so wedded in men's 
minds, that the heightened temperature in inflammation and 
fever has contributed more than anything else to beget the idea 
of the phenomena of disease being due to excess of vital action. 

It is true that the heat of the body is greater in fever ; but 
that is no positive proof that more is elicited, only that more is 
retained, than in health. Indeed, in many cases we can show 
clearly enough that the quantity produced is not augmented. 
Chill an inflamed part and a healthy part to the same point at 
the same time, and we find that the healthy part the soonest ar- 
rives at the normal temperature. Leave a fevered patient with 
his burning skin exposed to the air, and he will often grow 
colder than a healthy person under the like circumstances. Prob- 
ably a great deal of the heat of fever is due to deficient evapo- 
ration by the skin and lungs, and under that aspect would pre- 
sent itself as the direct result of deficient function. 

Sixth objection. — When people talk of " hyperesthesia," and 
of " sensibility being morbidly increased," they mean that more 
pain than ordinary is felt in certain parts. I cannot hear that 



ANSWERS TO OBJECTIONS. 631 

they ever find agreeable sensations augmented. No patient ever 
speaks of enjoying his morbid feelings ; his capacities in this 
respect are not raised. Nor have I ever found the organs of 
special sense made really more perceptive by disease. No sounds 
inaudible to the listening ear ever fall on the invalid's auditory 
nerve, nor are objects beyond the range of vision pictured on 
his retina. It is true that the pains they feel often make them 
attentive to slight sounds and distant sights, which the by- 
standers have passed over ; but these latter never fail also to 
hear and see them by a voluntary direction of the attention. 

Nor is common sensation rendered more accurate or delicate. 
I have tried, several times, by the test of its appreciation of the 
distance between the two points of a pair of compasses, whether 
a spot inflamed with gout had the perceptive faculties of its 
nerves heightened in comparison with the corresponding part of 
the opposite side. I have never found it to be so. I have tried 
the same experiment on parts affected with hysterical so-called 
" hyperesthesia," namely the brow and the left hypochondrium, 
and the delicacy of touch seemed, if anywise altered, to be 
lessened. 

Therefore to call these pains an increase of sensibility is in- 
correct. 

The increase of painful sensation in disease is of two kinds : 
first, the exaltation of it in parts which are naturally sensitive ; 
and secondly, its establishment in parts which normally have no 
feeling. Can either be viewed as an augmentation of life ? Test 
the first by the gradual production of indubitable local death in 
a part. Burn a portion of skin with fire or a caustic, or pro- 
duce a slough by pressure ; — the entire death or mortification is 
always preceded by pain. And this pain goes on getting worse 
and worse the nearer to death the spot approaches, till its sud- 
den cessation at the period of the virtual disconnection of the 
part with the individual. It seems unreasonable to suppose that 
the nearer death a part is, the higher should be its life ; and we 
cannot therefore accept heightened capacity for pain as proof of 
heightened life. 

The occurrence of pain during the inflammation of tissues des- 



632 ANSWERS TO OBJECTIONS. 

titute of nerves and insensible under ordinary circumstances, 
such as the alimentary canal, cartilages, &c, is at first glance 
an argument telling strongly against the theories of disease and 
cure which I have propounded. It may be asked whether the 
sensitiveness of normally insensitive parts can' be viewed other- 
wise than as the extension of a vital function beyond its natural 
limit and therefore as an increase of life. For where is the pain 
felt ? In the uninjured nervous center. And where is the 
nerve that communicates with the center ? Not in the inflamed 
painful cartilage but at its border. By the disease, by the low- 
ering of life a physical change is effected in the cartilage up to 
its edge, and notice of that physical change is transmitted by 
the nerve. 

Since the publication of the second edition I have read ex- 
pressions of dissent from a principle which I think an important 
one, and which runs through the whole of my pathological rea- 
soning, namely that all departures from that normal state which 
renders a man capable of his ordinary duties are diseases. It 
is argued, for example, by the Professor of Physiology at King's 
College, that I have- no right to class as diseases diarrhoea and 
diuresis, which may be produced by a medicine in the end 
beneficial. 

A grave principle is here involved. 

It seems to me of the utmost importance for the pathologist 
to recognize that every phenomenon which is not health is dis- 
ease, and essential to the proper understanding of morbid states 
to see that the external motive cause makes no difference in their 
true nature. The state in question is the same whether induced 
by a physician's drug, or by a felon's poison, or an epidemic ma- 
laria, climatic influences, or organic changes in a patient's body. 
In fact it would obstruct all true progress if we called the state 
when intentionally produced by one name, and when uninten- 
tionally arising by another. In point of fact the world does not 
do so, and when they are "ill of the doctors," patients call 
themselves quite as ill as when otherwise laid up. 

The words "health" and "disease" must be employed; and 



ANSWERS TO OBJECTIONS. 633 

if they are employed, the line between them must be drawn 
somewhere, or each speaker will assign to them a different sense. 
Where shall we find a line more convenient than that most in 
accordance with common usage ? 

An objection has also been raised to my counsel to medical 
men to turn their thoughts toward adding to rather than to 
diminishing the materials of growth in disease. The instance of 
pneumonia has been quoted, where it is said our aim should be 
to diminish the lymph in the lungs. Now I suppose nothing is 
so calculated to diminish the materials of lymph as mercury and 
frequent venesection ; yet mercury and frequent venesection 
are amply proved by experience not to be the most successful 
means of treating pneumonia. I am sure that the mode of 
managing the patient by supplying the materials of which lymph 
is made, as set forth in the lectures on pneumonia, and possibly 
practiced by the objector himself, is much more efficacious. 

I trust nobody will understand me to claim any exclusive prop- 
erty of invention in the plans of treatment which I advocate. 
They are those now adopted by the most earnest and liberal- 
minded hospital physicians. As Dr. Hayes truly says in the 
"American Journal of the Medical Sciences," I try to "embody 
into a system the common sense of clinical experience." Per- 
haps this is a less ambitious task than the building up of theories 
anticipatory of experiment, but I am sure it is more likely to 
lead to useful results. 



41 



L'ENVOI. 

In saying farewell, I would take the opportunity of pressing 
upon students the importance of making physiology the key- 
stone and binding link of all their knowledge, and the firm 
foundation which they are to crown with their future practice. 
It is an error, deadly to the usefulness of our profession, to say 
or do anything to foster an idea that the organic laws of health 
and disease are different; it is still worse to paint them as in 
opposition. On the modern principle of dividing labor we have 
separate lectures on anatomy, physiology, pathology, and the 
practice of medicine; but your instructors and you should never 
lose sight of these as branches of one study, as being in truth 
all limbs of the same tree, those who follow them one after the 
other are still pursuing the same end — a knowledge of man's 
nature, with a view to the culture of his physical well-being. 
Each special professor has no more right to claim the sole teach- 
ing of you to be medical men, than the shepherd, the weaver, 
or the tailor can arrogate to himself the credit of adorning our 
backs. 

I have studiously taught you that no new modes of nature's 
acting are brought into play by disease; its chemistry is the 
organic chemistry of health; the same mechanical laws are ex- 
hibited ; the relations of the material and spiritual world therein 
are the same. The difference consists in the deficiency, that is, 
the temporary or permanent subtraction, of substance or power, 
and not in its unwonted increase. 

I will frankly grant that this teaching is at issue with certain 
notions about disease handed down from ancient times, and in- 
fluencing the practice even of our immediate predecessors. Ac- 



L'ENYOI. 635 

cording to them disease appears in the light of a positive material 
or agency alien to the body, to cast out which must be our prin- 
cipal aim in our endeavors to restore health. 

This idea has several branches. Some look upon the morbid 
phenomena as u an effort of nature to destroy some noxious mat- 
ter, and to recover the patient by expelling it from his body."* 
It would make the chief business of the physician consist in 
watching the proper moment for aiding this elimination, in setting 
it going, or in substituting instead of it an artificial outlet for 
the "morbific material." 

Other branches are the chemical and antidotal systems of 
treatment, which have nearly the same pathology; they look 
upon disease as an active foreign substance, which only requires 
to be. rendered inert for the patient to be restored to health. A 
materies morbi is presupposed in either case. 

That a few diseases are the result of the introduction into the 
body, or of the formation in the body of a foreign noxious agency 
may be frankly conceded ; and if we could keep this agency out 
we should keep the patient well. But even in those special 
cases we cannot but see that the morbid phenomena continue to 
be displayed after the expulsion of the excitant; the wound 
remains after the sword is withdrawn, the burn is as painful 
when the fire is out, the chill is felt after our return to warmth 
and comfort, the stomach is inflamed though the irritant poison 
may be neutralized. The disease we have to cure is not the 
materies, but its consequences. 

Besides which, this noxious matter is in most instances not 
foreign to the body at all, but a necessary part of it, only re- 
quiring the addition of a fresh constituent, or renewed function, 
to render it again efficient. Such is acid in the stomach and 
colon, super-alkaline blood, anasarcous serum in the tissues. To 
expel them is to deprive the body of its substance, and certainly 
is injurious practice in most cases. 

To another physician the morbid phenomena present a different 
aspect. He regards them solely as exhibiting a phase of nature 

* Sydenham (Obs. Med., cap. i) defines disease to be "Naturae conamen^. 
materia morbificse exterminationem in segri salutem omni ope molientis." 



636 I/ENVOI. 

different from, and opposed to, normal anatomy and physiology. 
Disease is to him an active and intelligent living foe, at war 
with his friend the human body, with a military system of its 
own, to be studied and outmanoeuvred. There is a contest be- 
tween Ormuzd and Ahriman; the agencies under the command 
of the normal life are arranged against the pathological life.* 
On these grounds, it would seem the main duty of the medical 
man to "weaken life,"f for it cannot be denied that these patho- 
logical phenomena are in a great measure of a vital nature. 
What this physician fails to recognize is, that their vitality is 
the deformed remains of the normal vitality, that they are an 
evidence of deficiency, not something in excess, in fact that dis- 
ease is "something less than life." 

I am sure that physiology as it is now taught in our schools 
is enough to clear away the remaining mists of these supersti- 
tions. They cannot stand before the light. To us now health 
is that nicely adjusted balance of vital functions which is con- 
venient for the uses men put their bodies to, or ease; that dis- 
ordered balance which is inconvenient is bad health or dis-ease. 
There are no foreign forces to be studied, but simply varied 
relations arising from deficiency of one or other of the ordinary 
functions of life, and a consequent want of balance between 
them. 

Is it not, then, obvious that the only sure mode of arriving at 
a knowledge of the deficiencies of vital powers, or diseases, is by 
a knowledge of those powers of which they are deficiencies? The 
physiologist is the only true pathologist. 

And as to the use of medicines, with which it is a student's 
duty to be acquainted, do you not see that the safest guide to a 
knowledge of their effect upon a disordered body is the knowl- 
edge of their effect upon a healthy body, and that the most 
certain way of advancing the art of healing is to search out the 
essential actions of physical agents? 

* "Krankheit ist der Kampf des egoistischen Princips (des besondern Lebens) 
mit dem planetarischen, der schadlichen Potenz, die es zu zerstoren sucht." — 
Schonlein's "Allg. Patkologie," s. 1. 

f See Lecture V in this volume, p. 86, note. 



L'ENVOI. 637 

To the practitioner I will urge the need of gaining firm faith 
in the work he is busy upon, and using only the tools he can 
trust. Without this he can look back with no conscientious joy 
on his daily toil, his moral nature will become baser and baser 
day by day, he will have but the slighting scorn of those whose 
praise he should value in old age, and, worse than all, he will 
deserve it. The sooner a skeptic leaves our profession the better 
for his peace of mind. 

Remark, that by a skeptic is not meant one who disbelieves 
what somebody else believes in, and which reason shows to be 
inconsistent with that which he himself has ascertained to be 
true. The early Christians were not skeptics, when they rejected 
the idols which their better faith told them were false gods. 
Galileo was not a skeptic, when he found the Ptolemaic astronomy 
inconsistent with his own. A skeptic is one who begins by pull- 
ing down, w T ho scornfully calls useless the means which yet he 
traditionally employs, before he has got better to take their 
place. Such a turn of mind never has led to truth. 

The right-thinking practitioner will, as Sydenham did, gain 
with advancing experience more faith and confidence in physio- 
logical and restorative treatment, will be less driven to fly timidly 
to destructive expedients. Like that great and honest-minded 
man he will cease to resort to u vense sectio^ in cases where he 
has found the effect of " serum lactis" sufficient. 

To non-professional persons* I would say, examine for your- 
selves and see that the art of healing is a true woik, not a set 
of rules, not a doctrine, but a real means of adding to life and 
happiness. See — for you can see if you like — that her founda- 
tions are not opinion or traditional notions, but a sure knowl- 
edge of God's works. Look and see that not cleverness, or 
knack, or habit learned from others can be the chief virtues of 
the professor of this art. There is scope in it for the highest 
and broadest intellects, for wisdom, prudence, and judgment, as 

* These sentences are taken from a general school introductory lecture given 
at St. Mary's for the opening of the session in October, 1856; to which, accord- 
ing to usual custom, parents and other non-professional friends of students are 
admitted. 




638 L'ENVOI. 

well as for the moralities of perseverance and charity. He in 
our profession who is first in the scale of humanity is the first 
and best physician. 

I would call upon all to remember what a high matter it is that 
we take upon ourselves to handle. Man's life! — that which 
makes him God's viceroy on earth ; for divorced dust and spirit 
cease to hold that lofty post. To aid us in our duty we are 
dowered with dominion over not only brute matter which we can 
number and weigh, but over those unseen forces which our reason 
makes known to us ;heat, electricity, vitality, and maybe other 
yet nameless " powers of the Lord." Our business is to use them 
to lengthen and lighten man's earthly trial. Every minute that 
our ministrant zeal upholds it in vigor fosters a fresh hope of 
working out salvation for himself and others; every minute by 
which it is shortened damps that hope. 



